Table 1 Root/uncomplicated vignettes and additions for cross-cutting factors

ADHD

An 8 year-old boy, who has been a patient of yours for several years, has no known developmental issues, no chronic health problems, and lives with a stable, well-functioning family. He has long had moderate academic difficulty in school despite good effort; today he comes with his mother who has brought a packet of Vanderbilt forms (mostly positive) that the school counselor collected from his main classroom and “resource” teachers. His mother has said previously that she would be interested in exploring the possibility of using medications if it would help him do better in school.

Medical co-morbidity

Born prematurely, always been a picky eater; has tracked along growth at about the 10th percentile with a low but consistent ratio of weight for height.

Difficult family

Family has always been a bit more demanding; mother feels that teachers are too quick to blame child rather than spending time helping him with work.

Psychiatric co-morbidity

Child often says to family that he is “dumb” and would rather do things alone instead of playing with his classmates.

Anxiety

An 11 year-old boy you have followed in your practice has no chronic medical problems, though you have perhaps had more than the usual number of after-hours phone calls about concerns from his mother. This year he started middle school, and his mother is out of the home more than in the past because of a job change. He now wants a light on in his room at night, and will sometimes awaken and say that he has had a bad dream or can’t sleep because he is worrying about an upcoming school deadline. Despite all this, his school performance remains reasonable, and he still plays with friends and enjoys his other activities.

Medical co-morbidity

Has well-controlled asthma (uses mostly only a maintenance inhaler). However, in the past, he had some serious episodes and once had to be admitted to the ICU.

Difficult family

The family has always been a bit difficult, coming late for appointments, getting behind on immunizations; mother thinks the child is just reacting to father’s more no-nonsense approach.

Psychiatric co-morbidity

Some mornings does not want to get out of bed to go to school; trembling as said goodbye to get on the bus, wet the bed one night for the first time since toddler.

Depression

A 15 year-old girl who has been a patient in your practice since early childhood has no major medical problems and her medical transition to adolescence seems to have gone smoothly. However, partway through her first year in high school, her good grades and good mood seem to have fallen off some. This comes to light at a visit prompted by a concern for low energy and her mother wondering if she could have “mono” or Lyme disease. You talk to the patient alone and find that she is worried about her father, who has a serious illness, and that she has had trouble finding her place among new social circles in school. She says that her appetite is off, her sleep is restless, and she is spending more time to herself. However, she has no thoughts of harming herself and there is no history of self-harm in her past or in her family.

Medical co-morbidity

Has juvenile onset diabetes but with good adherence to treatment and good adjustment to having a chronic condition.

Difficult family

Family has always seemed demanding; mother dismisses patient’s concerns about her father as “excuses” and insists on blood tests.

Psychiatric co-morbidity

Some past history of mood fluctuation; once ran away to a friend’s house; when distressed rubs her arm with a pencil eraser until the skin is raw to “drown out” her problems; asks not to tell mother “because it will just make it worse” but has no suicidal ideation or other risk behaviors.