ADOS 2 – Module 3 - Fluent Speech – Child/Adolescent

Subjective:
Chief Complaint:
Follow-up for ADHD management and medication effectiveness

History of Present Illness:
Lucas presents for follow-up regarding attention-deficit/hyperactivity disorder management and assessment of medication effectiveness. Earlier in the academic year, there were reported difficulties with sustained attention in class, frequent talking during lessons, and episodes of impulsivity. Lucas has been maintained on a 40 milligram dose of medication for an extended period. He reports subjective improvement in concentration, particularly in science classes, though he continues to experience difficulty maintaining focus in mathematics, which he describes as less engaging. Lucas expresses a preference for physical education and participates actively in basketball. His parents have observed increased fatigue and report that he has difficulty initiating sleep despite adhering to a bedtime of 9:30 PM. Appetite has decreased, with reduced intake in the morning and incomplete consumption of packed lunches. No additional concerns regarding mood or behavior at home or school are reported at this time.

Past Medical History:
Lucas has a diagnosis of Attn-defct hyperactivity disorder, predom inattentive type (F90.0). He has been maintained on a 40 milligram dose of medication for an extended period. There is a history of difficulties with sustained attention in class, frequent talking during lessons, and episodes of impulsivity earlier in the academic year. He has demonstrated subjective improvement in concentration, particularly in science classes, with ongoing challenges in mathematics. No additional concerns regarding mood or behavior at home or school have been reported.

Social History:
Lucas is currently enrolled in school and participates actively in physical education, with a particular interest in basketball. He reports that physical activity, especially basketball, contributes positively to his confidence. There is no indication of difficulty with physical activity or sports.

Development:
Lucas's height is in the 85th percentile and his weight is average for his age and sex, indicating appropriate growth. No concerns regarding developmental milestones have been raised.

The Review of Systems:
General: Lucas reports increased fatigue and difficulty initiating sleep despite adhering to a bedtime of 9:30 PM. No mention of difficulty focusing in science. No mention of difficulty with physical activity or sports.
Gastrointestinal: Appetite has decreased, with reduced intake in the morning and incomplete consumption of packed lunches.
Psychological: Lucas reports feeling more confident, particularly when participating in basketball.

Current Medications:
Lucas is currently taking a 40 milligram dose of medication for attention-deficit/hyperactivity disorder. The only reported side effect is difficulty initiating sleep. No mention of medication side effects other than difficulty sleeping.

Nutritional History:
Lucas's dietary intake includes a small breakfast and a packed lunch, which he does not always finish. His appetite has decreased. Soda consumption is not excessive, and occasional intake is permitted. The physician recommended switching to no-sugar sparkling water. No mention of significant weight loss or gain.

Adolescent History:
Lucas is engaged in regular physical activity through participation in basketball and physical education. He reports increased confidence associated with sports. There are no reported concerns regarding mood, self-harm, or social integration. Academic performance has improved in science, with ongoing challenges in mathematics.

Objective:
ADOS 2 – Module 3 - Fluent Speech – Child/Adolescent:
ADOS 2 – Module 3 - Fluent Speech – Child/Adolescent

Lucas demonstrates fluent speech with age-appropriate expressive language. Utterances are complete and coherent, and he is able to engage in reciprocal conversation. No expressive or receptive language deficits are noted. The number of activities and codes assessed is not specified in the encounter documentation.

1. Construction Task: No information available.
2. Make-Believe Play: No information available.
3. Joint Interactive Play: Lucas participates actively in basketball and physical education, indicating engagement in joint play activities.
4. Demonstration Task: No information available.
5. Description of a Picture: No information available.
6. Telling a Story From a Book: No information available.
7. Cartoons: No information available.
8. Conversation and Reporting: Lucas is able to converse about his school experience, preferences, and challenges, and reports on his own focus and confidence.
9. Emotions: Lucas expresses feelings of confidence, particularly when participating in sports, and is able to discuss his preferences and challenges.
10. Social Difficulties / Annoyances: No social difficulties or annoyances are reported by Lucas or his parents.
11. Break: No information available.
12. Friends & Marriage: No information available.
13. Loneliness: No information available.
14. Creating a Story: No information available.

Physical Examination:
Lucas's height is in the 85th percentile and his weight is average for age. Growth parameters are within normal limits. No abnormalities were noted on general inspection.

Assessment and Plan:
- Attention-deficit hyperactivity disorder, combined type (F90.2): Lucas demonstrates improvement in attention and behavior on current medication regimen, with ongoing difficulty focusing in mathematics and decreased appetite. He experiences increased fatigue and difficulty initiating sleep, likely related to medication side effects.
Plan:
• Continue current medication at 40 milligrams daily.
• Monitor for changes in sleep patterns, appetite, and school performance.
• Encourage use of a visual checklist to support morning routines and promote independence.
• Advise limiting sugary drinks and recommend no-sugar sparkling water as an alternative.
• Reinforce the importance of adequate nutrition, especially given high activity levels.
• Schedule follow-up appointment in the summer to reassess medication effectiveness, sleep, appetite, and academic progress.
• Provide positive reinforcement for participation in sports and encourage continued engagement to support confidence and focus.