Start with an open question

Begin with an open, purposeful question.

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

This allows the father to describe the behaviour, his concern and his expectations.

Time-efficient data gathering

Use a structured approach:

• What behaviours are concerning?
• When did they start?
• Where do they occur?
• Who has noticed them?
• What is happening at home, school and between parents?
• What is the impact?
• What has already been tried?

Summarise early to ensure you are addressing the right problem:

“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 helps:

• Demonstrate synthesis.
• Check the agenda.
• Avoid premature diagnosis.
• Keep the consultation focused.

High-yield questions

Behaviour pattern

• “What does Ricky do that worries you most?”
• “How often does it happen?”
• “How long has it been going on?”
• “Is it getting worse, better or staying the same?”

Settings

• “Does this happen at school?”
• “Have his teachers raised concerns?”
• “Does it happen at his mum’s house?”
• “Is the behaviour different when he is with different people?”

Impact

• “Has this affected Ricky’s school, friendships or family life?”
• “Is it affecting your relationship with him?”
• “Does it affect daily routines like bedtime, meals or getting ready?”

Family context

• “How often does Ricky see each parent?”
• “Are routines similar between homes?”
• “How has Ricky seemed since the separation?”
• “How is communication between you and Ricky’s mum?”

Sleep and routine

• “How is Ricky sleeping?”
• “What is his bedtime routine like?”
• “Does he use screens before bed?”
• “Is he tired during the day?”

Expectations

• “What were you hoping would happen today?”
• “Were you hoping for a referral, advice, or something else?”
• “What worries you most if this continues?”

Functional, psychosocial or contextual assessment

Explore:

• Parental separation.
• Consistency of routines between homes.
• Emotional impact on Ricky.
• Parenting stress.
• Communication between parents.
• Sleep patterns.
• School functioning.
• Friendships.
• Family life.

Be curious, not judgemental. Family structure, routines and stressors are often key to understanding child behaviour.

Explore ideas, concerns and expectations

If the father is seeking diagnosis or treatment:

“It sounds like you’re wondering whether this could be ADHD and whether Ricky needs a referral or medication. Is that right?”

Then explore:

• What he understands by ADHD.
• Whether he expects medication.
• Whether he feels under pressure or unsupported.
• Whether he has tried behaviour strategies.
• Whether he wants school or parenting support.

Recognise and respond to cues

Important cues include:

Parental separation

This may contribute through stress, emotional insecurity, inconsistent routines or different discipline between homes.

Father wanting referral or medication

This may reflect frustration, stress or belief that a medical solution is needed.

Behaviour only happening at home

This is diagnostically important because ADHD should cause impairment in more than one setting.

Ricky’s mother not being involved

ADHD assessment needs input from both parents and school where possible.

Useful response:

“To get a full picture, we really need to understand how Ricky is in all the places he spends time — with you, with mum and at school.”

Useful consultation phrases

“ADHD stands for Attention Deficit Hyperactivity Disorder. It can affect how a child concentrates, stays still and manages their impulses.”

“Children with ADHD are often more active than other children their age, can be more impulsive and may 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 learning, relationships or daily routines.”

“Some children have lots of energy or are struggling with changes around them, like big changes at home or not getting enough sleep, and that can look similar to ADHD.”

“Getting more information will help us work out whether this is ADHD or something different.”

Consultation flow and signposting

1. Explore the father’s main concern.
2. Clarify Ricky’s behaviour: what, when and how often.
3. Ask where it happens: dad’s home, mum’s home, school.
4. Explore impact on school, friendships and family life.
5. Explore sleep, routines and family separation.
6. Clarify father’s expectations about referral or treatment.
7. Summarise and check accuracy.
8. Explain ADHD diagnostic principles.
9. Agree information gathering and support plan.
10. Arrange follow-up and safety-netting.

Summarising and checking understanding

A helpful synthesis might be:

“From what you’ve told me, Ricky is very active and can struggle to focus when he is with you, but school has not raised concerns and we do not yet know whether mum is seeing the same pattern. This started after the separation, so we need to understand whether this is ADHD or a response to changes and routines.”

Check:

“Does that sound right? Is there anything important I’ve missed?”

Data gathering self-check

Before moving to management, the trainee should know:

• What behaviour is concerning.
• How long it has been present.
• Whether it occurs in more than one setting.
• Whether school has concerns.
• Ricky’s mother’s perspective, if known.
• Impact on learning, friendships and routines.
• Sleep pattern and bedtime routine.
• Parental separation and custody arrangements.
• Consistency of routines between homes.
• Father’s expectations about referral or treatment.
• Whether there are safeguarding or significant stress concerns.

Assessment domain mapping

Data gathering

• Behaviour pattern and duration.
• Settings: home, school, mother’s home.
• Impact on family, school and friendships.
• Sleep, routines and family context.
• Father’s concerns and expectations.

Clinical management

• Explain ADHD diagnostic requirements.
• Gather school and mother’s views.
• Behaviour diary and sleep diary.
• Parenting support.
• School nurse or Early Help input.
• Follow-up and safety-netting.

Relating to others

• Non-judgemental exploration of family separation.
• Validating parental concern.
• Avoiding premature diagnosis.
• Shared planning with both parents where possible.

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Prioritised differential diagnosis or clinical reasoning

Appropriate differential, based on NICE NG87 and the case details:

1. Normal range development or temperament variation — most likely.
2. Disrupted behaviour secondary to sleep deprivation.
3. Situational reaction to family breakdown or separation.
4. Adjustment disorder.
5. Neurodevelopmental disorder, such as ADHD — less likely if not seen in more than one setting.
6. Anxiety or mood disorder — rare at age 5, but possible if further cues are identified.
7. Other medical or neurological cause — rare, such as hearing or vision problem or epilepsy.

Clinical reasoning script

“At Ricky’s age, lots of children are very active. ADHD is one possible explanation, but we usually need to see difficulties in more than one setting, such as home and school, and we also need to think about sleep, routines and family changes. Because this seems mainly at home so far, the next step is to gather more information before deciding whether this is ADHD.”

Red flags and risk assessment

Monitor for:

• Behaviour worsening.
• New concerning features.
• Significant impairment at school, home or with friendships.
• Safeguarding concerns if identified.
• Significant family stress.
• Symptoms suggesting sleep deprivation.
• Possible hearing, vision or neurological issues if raised by history.

Decision points

Key decisions include:

• Is Ricky’s behaviour present in more than one setting?
• Has it been present for at least 6 months?
• Is there at least moderate impairment?
• Could sleep, family stress or normal development explain the behaviour?
• Do both parents and school need to provide information?
• Is referral appropriate now, or should information gathering and support come first?
• Is parenting support or Early Help needed?
• Is there any safeguarding concern?

Management priority

The management priority is to gather a fuller picture and support the family now, rather than jumping straight to diagnosis or medication.

Management options

1. Reassurance

Explain that many 5-year-olds are very active and this can be within normal development.

Avoid dismissing the father’s concern. Reassurance should be paired with a plan.

2. Gather information from Ricky’s mother and school

With appropriate consent, seek information from:

• Ricky’s mother.
• Teachers.
• School staff.

Example phrase:

“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.”

3. Behaviour and sleep diary

Encourage both parents to keep a diary of:

• Concerning behaviours.
• Triggers.
• Timing.
• Sleep patterns.
• Bedtime routine.
• Screen use.
• What helps.

This may identify patterns or situational triggers.

4. Sleep hygiene advice

Discuss normal sleep patterns and practical sleep hygiene:

• Consistent bedtime.
• No screens before bed.
• Wind-down routine.
• Consistent routines across homes where possible.

5. Parenting support

Signpost to parenting support programmes or local parenting classes.

These are first-line and recommended in NICE NG87 for primary-school-age children showing hyperactivity or behaviour difficulties.

6. School nurse or Early Help support

Consider:

• School nurse involvement.
• Early Help.
• Family Front Door.
• Parenting or behaviour advice.

7. Monitoring and follow-up

Arrange review in a few weeks to see whether the behaviour changes or persists and to review information from school and Ricky’s mother.

8. Safety-netting

Advise earlier review if:

• Behaviour worsens significantly.
• New concerning features appear.
• School raises concerns.
• Family stress escalates.
• Safeguarding concerns emerge.

Personalised plan

A plan tailored to this family might include:

• Explain why ADHD cannot be diagnosed from behaviour in one setting.
• Ask the father to speak with Ricky’s mother about behaviour at her home.
• With consent, gather school or teacher perspective.
• Keep a behaviour and sleep diary.
• Offer sleep routine advice.
• Signpost to parenting support.
• Consider Early Help if family stress is significant.
• Arrange follow-up in a few weeks.
• Invite Ricky’s mother to a future appointment if appropriate.

Example phrase:

“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?”

Shared decision-making

Agree shared goals with the father:

• Understand whether Ricky’s behaviour happens in more than one setting.
• Improve communication between parents.
• Support consistent routines.
• Decide whether referral is needed based on fuller information.
• Reduce stress at home.

Ask:

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

Safety-netting

Explain that the family should seek review earlier if:

• Ricky’s behaviour becomes unsafe or much more difficult to manage.
• School or nursery reports significant concerns.
• Sleep deteriorates.
• Ricky becomes very distressed or withdrawn.
• New developmental, hearing, vision or neurological concerns appear.
• Safeguarding or family-stress concerns arise.

Ethical, legal and safeguarding considerations

Consider:

• Clarify custody and communication arrangements.
• Avoid misunderstanding between separated parents.
• Support co-parenting where possible.
• Be curious, not judgemental, about family structure and routines.
• Escalate if safeguarding or significant stress concerns are identified.

Documentation points

Document:

• Father’s concerns and expectations.
• Behaviour described.
• Duration and settings.
• School view, if known.
• Mother’s view, if known.
• Parental separation and routine differences.
• Sleep and diary advice.
• ADHD explanation and diagnostic requirements discussed.
• Parenting support or Early Help signposting.
• Follow-up plan.
• Any safeguarding concerns or absence of such concerns.

Common unsafe management plans

Avoid:

• Referring for ADHD assessment without checking settings and impairment.
• Offering medication or implying ADHD diagnosis prematurely.
• Ignoring school and mother’s perspectives.
• Dismissing the father as overreacting.
• Failing to explore sleep and family separation.
• Not arranging follow-up.
• Ignoring safeguarding concerns if they emerge.

Follow-up and coordination with other professionals

Coordinate with:

• Ricky’s mother, with appropriate consent and involvement.
• School or teachers.
• School nurse.
• Early Help or Family Front Door where appropriate.
• Parenting support programmes.

Follow-up should review:

• Behaviour diary.
• Sleep patterns.
• School feedback.
• Mother’s feedback.
• Impact on family life.
• Whether symptoms are persistent and impairing across settings.
• Whether referral becomes appropriate.

Learner checkpoint

Have I gathered enough information across settings before deciding whether ADHD assessment is appropriate?

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Relevant guidance areas

This includes guidance and resources on:

• ADHD diagnosis and management.
• Consultation structure and synthesis.
• Parent training and behaviour support.
• Relating to others in consultation.
• Family context, routines and co-parenting.

NICE guidance

• NICE NG87: ADHD in children and adults.

RCGP and SCA resources

• RCGP SCA Toolkit: Relating to Others.
• MRCGP annual reports and research.

Key principles to remember

• Start with the parent’s story and main concern.
• Synthesis matters: do not just collect data.
• ADHD diagnosis should not be based on symptoms in one setting only.
• Symptoms should be present for at least 6 months, evident before age 12 and cause at least moderate impairment in more than one setting.
• Consider sleep, anxiety, adjustment, family stress and developmental stage before referral.
• Behaviour only at home suggests possible situational or family-context triggers.
• Input from both parents and school is important.
• Parent training programmes are first-line for primary-school-age children with hyperactivity or behaviour difficulties.
• Use follow-up to review diaries, school input and parental perspectives.

Transferable learning for future cases

In child behaviour consultations:

• Ask where the behaviour happens, not just what the behaviour is.
• Explore family changes, sleep and routines before medicalising.
• Use summaries to check you are solving the right problem.
• Involve both parents and school where appropriate.
• Pair reassurance with practical support and follow-up.
• Avoid premature diagnostic labels.

Supervisor or examiner lens

A supervisor or examiner is likely to look for:

• Open, structured data gathering.
• Recognition that symptoms only at home make ADHD less likely.
• Exploration of parental separation and routines.
• Explanation of ADHD diagnostic requirements.
• Plan to gather school and mother’s input.
• Parenting support and sleep advice.
• Follow-up rather than premature referral or dismissal.

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Final learner takeaway

Possible ADHD in a 5-year-old requires synthesis across settings: behaviour only at home is a cue to explore sleep, routines and family context before diagnosing.

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