Office Visit Note
Narrative: ## Outpatient Psychiatric Progress Note **Identifying Information** Patient is a 13-year-old male with a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD), unspecified type. Parents are present for this telehealth medication management session. **History of Present Illness** Parents initiated this follow-up appointment to discuss recent feedback from the patient's therapist (Rochelle) and to review medication side effects. The patient's therapist suspects the patient may have Autism Spectrum Disorder (ASD) and is planning to conduct further testing used for older children and adults. Parents report feeling "much better" and less "blue" than the previous session, as they feel they have a better understanding of the patient's challenges. The primary concern raised by parents is potential emotional blunting secondary to medication. They note a loss of interest in previously enjoyed activities, such as swimming, stating, "he could just give a shit about swimming." While he remains interested in mountain biking, his general response to many situations is, "I do not care." Parents are concerned this apathy could be a side effect of sertraline. Patient continues to take guanfacine 1.5mg BID (3mg total daily dose) and sertraline 75mg daily. Parents report no issues with sedation from guanfacine. Patient reportedly states he feels "less anxious" on the medication. Regarding recent behavioral concerns, parents report the school incident (inappropriate comment to a peer) was handled with a "benefit of the doubt" approach by the school, and no suspension occurred. Patient's reaction was reportedly, "see, I told you it wasn't a big deal." Parents note he has been more compliant and less argumentative at home, particularly regarding his lack of a cell phone. **Mood and Affect** Parents report the patient's mood is generally "neutral" and apathetic. They describe a significant decrease in his previously endorsed anxiety; he no longer reports feeling anxious. During the session, parents' affect was appropriate to the content, shifting from concerned to more hopeful. **Behavior and Appearance** This was a telehealth session with parents only; patient was not observed. Parents describe the patient's behavior at home as improved, with less conflict with his younger sibling and a reduction in impulsive outbursts. They note he is compliant with taking his medications and supplements from his "old man's pillbox." **Thought Content and Process** Parents report concerns about the patient's apathy and flat emotional responses, questioning if medication is "medicating a conscience out of our kid." They note his thinking can be very literal and concrete, requiring specific, explicit rules rather than generalizing social norms. For example, "I have never been told specifically that I can't make fun of someone for this exact reason." He reportedly has poor memory for impulsive verbalizations. No current suicidal or homicidal ideation was reported by parents. **Insight and Judgment** Patient's insight into his social challenges appears limited. He minimizes the severity of his actions at school and seems to lack understanding of their social impact. Parents' insight has improved significantly; they feel they have a better framework for understanding his behavior, particularly with the potential for an ASD diagnosis. They are shifting their parenting approach from punitive to more supportive and structured. **Interventions and Therapeutic Techniques** Supportive therapy and psychoeducation were provided to the parents regarding medication side effects, specifically emotional blunting, and the interaction between ADHD, anxiety, and potential ASD. Motivational interviewing techniques were discussed to encourage patient agency in medication decisions. The rationale for the current medication regimen was reviewed. **Response to Treatment** Parents were highly engaged and receptive during the session. They expressed relief at having a clearer direction for the patient's care and appreciated the collaboration with the patient's therapist. They demonstrated an improved ability to reframe the patient's behavior and are implementing new parenting strategies (e.g., increased structured family time, physical cues for attention) recommended by his therapist, which they report has led to a "pretty harmonious" home life over the past week. **Plan and Recommendations** 1. Medication: Continue current medication regimen of guanfacine 3mg total daily dose and sertraline 75mg daily. The option to decrease sertraline to 50mg to assess for changes in emotional blunting was discussed, but the consensus was to make no changes at this time given overall improvements in mood stability and reduced conflict. Parents will continue to monitor for apathy and emotional flatness. 2. Therapy: Patient will continue therapy with Rochelle, who will proceed with additional testing for ASD. Parents will follow up with her recommendation to consult with an on-site nutritionist regarding supplements. 3. Coordination of Care: Parents will provide updates on any new supplement recommendations. They will also continue to advocate with the school for social-emotional support as outlined in his IEP. 4. Safety Plan: Continue to monitor patient's mood and behavior. Parents know to contact the provider if there are any acute concerns. 5. Follow-up: Schedule follow-up as needed. Parents will provide text updates, and it is understood that "no news is good news."