Impression:
Based on your review of the initial parent and teacher Vanderbilt behavioral rating scales, Ben’s medical history, your clinical observations, physical examination, and parent report, you conclude that Ben meets diagnostic criteria for ADHD, combined type.
**The Vanderbilt assessment helped you determine there were significant symptoms of inattention (at least 6 symptoms) and hyperactivity/impulsivity (at least 6 symptoms) present in at least two environments – home (parents report) and school (teacher report). Additionally the symptoms interfere with functioning (as noted by the presence of any performance problems on the Vanderbilt scale).
Recommendations:
You begin to discuss with Ben’s mother that based on his age and diagnosis, there are different treatment options to consider. Two important options are (1) parent behavioral management training and (2) medication management.