Case laboratory · fictional case
Rohan: a nine-year-old whose teacher says he 'never listens'
A teacher refers a nine-year-old for inattention and incomplete work. ADHD is one hypothesis among several — including hearing, learning, anxiety, sleep and family stress.
Stage 1 of 7
1 Observe
Presenting concerns
His teacher reports that Rohan does not follow instructions, rarely finishes written work and stares out of the window. His parents say he is 'fine at home but lazy with homework'.
Behavioural observations (clinic)
- Friendly and chatty in play; builds an elaborate block tower.
- On a reading task, he guesses words and asks repeatedly if he can stop.
- Leans toward the examiner when spoken to quietly.
Your turn: What stands out? Which observations might point in different directions?
Teaching discussion for this stage
Notice the contrast: sustained attention in play but avoidance of reading. Leaning in to hear quiet speech is a cue to check hearing. 'Lazy' is a label to replace with behavioural description.
2 Gather information
History
Developmental milestones were within the usual range, though speech was 'a little late'. He had repeated ear infections at ages 4–6. His school changed its medium of instruction to English two years ago.
Context
His grandmother has been unwell, and the household has been busy with hospital visits. Bedtime has drifted to 11 pm. His father works long shifts.
Available information
- Teacher and parent behaviour checklists disagree: high inattention at school, average at home.
- Recent school reports show reading well below class level; maths is near average.
Your turn: What could explain the difference between home and school reports?
Teaching discussion for this stage
Cross-informant disagreement is informative. It may reflect different demands (reading and listening at school), a learning difficulty, hearing problems, language of instruction, or situational factors — rather than one informant being wrong.
Missing information
- Formal hearing and vision tests.
- Reading and language assessment in both languages.
- Sleep duration.
- Anxiety about school or reading.
- Whether inattention was present before the medium-of-instruction change.
3 Generate hypotheses
Your turn: List competing hypotheses and the evidence that would distinguish them.
Teaching discussion for this stage
Avoid one symptom equals one diagnosis. Inattention is a final common pathway for many causes.
Possible hypotheses
- ADHD, inattentive presentation — would expect inattention across settings and from early childhood.
- Specific learning disorder in reading — would expect reading difficulties disproportionate to other abilities and despite instruction.
- Hearing impairment linked to past ear infections.
- Language-of-instruction demands.
- Insufficient sleep.
- Anxiety or stress related to grandmother's illness.
4 Formulate
Your turn: Draft a working formulation that links the factors, acknowledging uncertainty.
Teaching discussion for this stage
A working formulation might be: possible mild hearing loss after repeated ear infections, combined with reading demands in a second language and reduced sleep, leads to difficulty following instructions and avoiding written work; adults interpret this as laziness, his confidence falls and avoidance increases. The formulation is provisional until hearing and learning assessments are done.
| Factor | Biological | Psychological | Social / cultural |
|---|---|---|---|
| Predisposing | Repeated ear infections; mild speech delay | Possible reading difficulty | Instruction in a second language |
| Precipitating | Late bedtimes recently | Increasing reading demands in Class 4 | Grandmother's illness; household disruption |
| Perpetuating | Ongoing sleep loss | Avoidance of reading; low confidence | Labelled 'lazy'; homework conflict |
| Protective | Good general health otherwise | Sociable; persistent in play | Engaged teacher; caring extended family |
5 Plan assessment
Your turn: Plan a multi-method, multi-informant assessment.
Teaching discussion for this stage
The plan should test the competing hypotheses rather than seek to confirm one.
Possible next steps
- Audiology and vision checks.
- Standardised cognitive and academic assessment by a qualified psychologist, using tests appropriate to his language background and with caution about norms.
- Classroom observation with operational definitions of on-task behaviour.
- Developmental history focusing on early attention.
- Sleep diary.
- Brief child interview about worries.
6 Consider interventions
Fictional assessment results
- Audiology finds mild hearing loss in one ear; follow-up arranged.
- Reading is significantly below expectation; other abilities are average.
- Classroom observation shows inattention mainly during oral instructions and reading.
Your turn: Given these results, what supports would you recommend?
Teaching discussion for this stage
The findings point toward hearing and reading needs rather than ADHD — though a clinician would keep monitoring.
Evidence-informed options
- Seating near the teacher; instructions repeated and written down.
- Structured, evidence-based reading intervention.
- Regular bedtime routine agreed with the family.
- Praise and small rewards for effort (contingency management).
- Psychoeducation for parents and teacher replacing the 'lazy' label.
- Review whether attention concerns persist after hearing and reading needs are addressed.
7 Review outcomes
Fictional follow-up
After one term, with hearing follow-up, seating changes and reading support, teacher reports of inattention have reduced and Rohan completes more work. Reading remains below class level but is improving.
Your turn: How would you evaluate whether the plan worked, and what is next?
Teaching discussion for this stage
Compare repeated, operationally defined measures (on-task observations, work completion, reading progress) with baseline. Continue reading support, monitor attention, and schedule review. If inattention persists across settings despite these supports, a fuller ADHD assessment would be warranted.
Ethical questions and references
Ethical questions to discuss
- Who gives consent for a child's assessment, and how should the child's own views be sought?
- What are the risks of diagnostic labels in school records?
- How should assessment be adapted for a child taught in a second language?
References and resources
- Plante, T. G. (2005). Contemporary clinical psychology (2nd ed.). John Wiley & Sons.