Katie is an 8 year old Caucasian female who is brought to your office
today by her mother & father. They report that they were referred
to you by their primary care provider after seeking her advice because
Katie’s teacher suggested that she may have ADHD. Katie’s parents
reported that their PCP felt that she should be evaluated by psychiatry
to determine whether or not she has this condition.
The parents give you a copy of a form titled “Conner’s Teacher Rating Scale-Revised”.
This scale was filled out by Katie’s teacher and sent home to the
parents so that they could share it with their family primary care
provider. According to the scoring provided by her teacher, Katie is
inattentive, easily distracted, forgets things she already learned, is
poor in spelling, reading, and arithmetic. Her attention span is short,
and she is noted to only pay attention to things she is interested in.
The teacher opined that she lacks interest in school work and is easily
distracted. Katie is also noted to start things but never finish them,
and seldom follows through on instructions and fails to finish her
Katie’s parents actively deny that Katie has ADHD. “She would be
running around like a wild person if she had ADHD” reports her mother.
“She is never defiant or has temper outburst” adds her father.
Katie reports that she doesn’t know what the “big deal” is. She
states that school is “OK”- her favorite subjects are “art” and
“recess.” She states that she finds her other subjects boring, and
sometimes hard because she feels “lost”. She admits that her mind does
wander during class to things that she thinks of as more fun.
“Sometimes” Katie reports “I will just be thinking about nothing and the
teacher will call my name and I don’t know what they were talking
Katie reports that her home life is just fine. She reports that
she loves her parents and that they are very good and kind to her.
Denies any abuse, denies bullying at school. Offers no other concerns at
MENTAL STATUS EXAM
The client is an 8 year old Caucasian female who appears
appropriately developed for her age. Her speech is clear, coherent, and
logical. She is appropriately oriented to person, place, time, and
event. She is dressed appropriately for the weather and time of year.
She demonstrates no noteworthy mannerisms, gestures, or tics.
Self-reported mood is euthymic. Affect is bright. Katie denies visual or
auditory hallucinations, no delusional or paranoid thought processes
readily appreciated. Attention and concentration are grossly intact
based on Katie’s attending to the clinical interview and her ability to
count backwards from 100 by serial 2’s and 5’s. Insight and judgment
appear age appropriate. Katie denies any suicidal or homicidal ideation.
Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation
§ Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein,
J. N. (1998). Revision and restandardization of the Conners' Teacher
Rating Scale (CTRS-R): Factors, structure, reliability, and criterion
validity. Journal of Abnormal Child Psychology, 26, 279-291.