Notes from Dr.

Chan
History taking
HPI
Presenting complaint
Pathway to care
History of complaint
ascertain a symptom or not
onset, severity, impairment, progress, coping
system review to rule out co-morbidity
Background
family history
parents/ carers
Demographic data: age, occupation, working hour shift, trip, time and care for
patient, education level
PH: physical and mental
personality: temper, coping style, hobbies, ASD/ ADHD traits
Discipline and parenting: reasoning, lecturing and scolding, rewards and
punishment, corporal punishment, risk of abuse, inconsistency between parents
Relation with patients
Marital relation: handling of discord
Siblings
Family history of MI (mental illness)
Personal history
birth and developmental history
planned/ wanted, infertility
AN (antenatal)/ PN (postnatal)
carers
DMS (developmental milestone): speech, GM(gross motor), FM (fine motor),
social emotional, sphincters
medical history
school history: from teachers, academic result, conduct, peer relations, ECA
courtship
daily routines: timetable

MSE
appearance and behaviour
speech
mood and affect
thoughts
perception
sensorium and cognition
insight

MSE for child cases

observation
brief introduction
play by himself to warm up and how he plays and interacts with parents and CMO
(computer game not allowed coz even ADAHD can focus)
symptoms manifestation
3 step task: chinese, english writing, and drawing about his family or school, STM (short
term memory) [ask the child about the picture]
copying task: any dyslexia (a long passage, different age should be able to write
different numbers of words in a certain period of time)
interview the child alone: any separation anxiety
talk with him on family and then school, peer and classroom behaviour and studies, why
he comes this time
aspiration
Projective questioning on 3 wishes (if the goddess give you 3 wishes, what do you want?)
TOM tests for ASD
first order
second order
white lie
double bluff
12 stories


ADHD
Hyperactivity/ impulsivity (6/9) -
1. run about, climbs excessively in situations in which it is inappropriate (restless)
2. on the go or driven by a motor
3. fidgets with hands or feet or squirms in chair
4. leaves seat in classroom or other in which sitting is expected
5. difficulty playing in activities quietly bangs toys against wall
6. talks excessively and loud
7. difficulty awaiting turn
8. blurts out answer
9. interrupts or intrudes on other

clarifying the symptoms
1. run about, climbs excessively in situations in which it is inappropriate (restless)
is he a energetic child since small, high motor activities like running at home,
jumping or climbing furniture, running around at street, any sense of
dangerousness, waiting to cross the road or traffic light, hold cares hand, dashing
around at shopping mall, not bother to be with adults, getting lost, can he learn
from lessons
2. on the go or driven by a motor
does he being non-stop all the time, like a motor on the go
unable to take rest when tired, play till last minute, sleep less, eg afternoon naps,
birthday parties
always have to be occupied and find things to do
easy felt bored, excited
3. fidgets with hands or feet or squirms in chair
fidgety when seated
squirmy body, sit on edge, ready to stand up
hands touching things on table
turning bodies, rock bodies, poor posturing
kicking or gangling feet
slide down onto floor, legs up, buttocks up
4. leaves seat in classroom or other in which sitting is expected
often leave seat
home: meal time, HW time, how frequent, excuses
school: at KG, PS, able to sit through one class
others: interest class, church activities
5. difficulty playing in activities quietly
can he play by himself quietly
any banging of toys, self talk, making noise
how long would that last, exclude PC game
6. talks excessively
is he talkative

 noisy with him around, talks a lot and fast

volume of voice
like to chat in class
7. difficulty awaiting turn
wait for his turn in group games
able to queue up at different situation
school: KG to toilet, for school bus, for snacks
others: supermarkets, fast food restaurant, ocean park games
impatient, jump queue, grumbles, tend to give up, lost tract
8. blurts out answer
able to put up his hand and wait for his name called in class
answer questions of just blurt out to chit chat
in class, in group discussion
9. interrupts or intrudes on other
intrude conversation, activities of adults parents, eg when others are chatting or
over phone, try to give comment when not asked
unable to wait when asked
forget what to say afterwards

Inattention (6/9)
1. difficulty sustaining attention in tasks or play activities
2. easily distracted by extraneous stimuli
3. fails to give close attention to details or makes careless errors in schoolwork, or other
activities
4. does not seem to listen when spoken to directly
5. does not follow through on instructions and fails to finish school work, chores or duties
(not due to oppositional behaviour or failure to understand)
6. forgetful in daily activities
7. loses things necessary for tasks
8. difficulty organising tasks/ activities
9. avoids, dislikes or reluctant to engage in tasks that require sustained mental effort

clarifying the symptoms
1. difficulty sustaining attention in tasks or play activities
how short was the attention eg over homework
how long it takes to finish HW, compared with peer, need any supervision: 1:1
when playing toys: shift toys, not try to explore, short interest in new toys
not attentive in group games, not listening to coachs instruction
2. easily distracted by extraneous stimuli
how easy distracted: play with stationaries, toys, books, finger, any noise around,
off seat
or day dream: how parent cope with that, how to call he back, % of time
3. fails to give close attention to details or makes careless errors in schoolwork, or other
activities

4.

5.

6.

7.

8.

9.

how careless in HW, test

give examples: % of mark lost due to carelessness
does not seem to listen when spoken to directly
listen when talk to, able to pay attention?
how parents cope: with EC, face to face, ask him to repeat, write down
does not follow through on instructions and fails to finish school work, chores or duties
(not due to oppositional behaviour or failure to understand)
how many steps of commands he can follow through
how far he can do it, any losing tract, forget the commands
forgetful in daily activities
forgetful with daily tasks assigned by parents or teachers or when asked by
friends
bring back books, return memo, lib books
how parent cope: frequent verbal reminders or notes
loses things necessary for tasks
losing things frequently eg at school: books, stationeries, water bottles, clothes,
octopus card etc
forget where to put them, can he retrieve?
lost personal items like student card, phone, keys, toys when going out
difficulty organising tasks/ activities
unable to organise eg what uniform to wear for the occasion, what toolkits to
bring, remind other what to prepare
pack schoolbags properly, keep tidy or messy after school
avoids, dislikes or reluctant to engage in tasks that require sustained mental effort
dislike task with SME eg chess, puzzles, IQ questions, maths challenge
questions, tend to give up easily or quick to ask for answers instead of trying to
solve the questions

ADHD drugs 90% wont have side effects or can tolerate

ASD neurodevelopmental
clinical feature of autistic disorder
social
impair non-verbal social interaction
poor peer relationship
lack of spontaneous sharing
lack of emotional reciprocity
communication
delayed language development
impaired conversation, whether can sustain convos
odd language, echolalia
no spontaneous imaginative play
behavioral
preoccupied with restricted interest cars (wheels, door etc), line up car, bus, train
0 know everything in details in their interest but cannot say talent coz most .
rigid adherence to rituals
preoccupation with parts of objects
motor mannerism
SI(sensory integration) problems
Hyperreactivity afraid of sound, light (like Toby) etc, being hugged touching sth etc
Hyporeactivity likes to look at turning fan etc.
DSM-5 criteria for autism spectrum disorder
Currently, or by history, must meet criteria A, B, C, D
A. Persistent deficits in social communication and social interaction across multiple
contexts, not accounted for by general developmental delays, and manifest by all 3 of
the following:
1. Deficits in social-emotional reciprocity
2. Deficits in nonverbal communicative behaviors used for social interaction
3. Deficits in developing, maintaining, and understand relationships
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by
at least two of the following:
1. Stereotyped or repetitive speech, motor movements, use of objects
2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal
behavior, or excessive resistance to change
3. Highly restricted, fixated interests that are abnormal in intensity or focus
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory
aspects of the environment
C. Symptoms must be present in the early developmental period (but may not become
fully manifest until social demands exceed limited capacities)
D. Symptoms together limit and impair everyday functioning

Managemetn of ASD
Advice and support parents
Principles
- - Good laion among parties
- - Family focused
Appropriate education: school based
-
Theory of mind
first order TOM
sally and anne test
This is Sally. Sally has a basket. This is Anne. Anne has a box. Sally has
a marble. She puts the marble into her basket. Sally goes out for a walk.
Anne takes the marble out of the basket, and puts it into the box.
Now Sally comes back. She wants to play with her marble. Where will
Sally look for her marble?
the smarties test
a child is shown a smarties tube, and asked what they think is inside.
Natural, they nearly always say smarties
then they are shown that the tube actually contains pencils. Then they are
asked what they think a friend will say when they are brought in and
shown the tube, and asked what is inside
when I first showed you this tube, what did you think was in it? They will
often answer pencils
Second order TOM
This is Mary and John, they are school friends in the parks. Here comes the ice
cream van. John wants to buy an ice cream but he left his money at home. Ice
cream man says dont worry, Ill be in the park all day, youve got time to go
home.
John runs home to get his money. The ice cream man changes his mind & tells
Mary I cant stay here, Im off to the church. Mary goes home and the ice cream
man sets off to the church. But on the way the ice cream man meets John & says
Im off to the church now instead
In the afternoon, Mary goes to Johns house & knocks on the door. Johns mum
answer the door & says oh, John has gone out to buy an ice cream
Where does Mary think John has gone to buy an ice cream?
C= The park

PMT teach parent to manage the contingencies around child social behavior
- Promote desired behavior attention & rewards (catch your child being good)
- Extinguish unwanted behavior selective ignoring punishments (withdrawal of privilege)
times out from any positive reinforcement

Baumrinds parenting styles

- Authoritarian: high demanginness, low warmth ~ military training
- Permissive: high warmth, low demaningness ~ spoiling the child
- Authoritative: high warmth, high demandingness best
PMT: Nurturance and

Overall compliance to parents commands%
Non on what aspect and how parent handles
Worse temper outburst how severe and how freq how parent cope and latest situation
Screen ODD s/s
Screen CD s/s if presence of ODD s/s
Give you an impression how difficult is the child