Nathan Jones is a 6 year old boy referred to the community paediatrician by his general practitioner. He has an older brother, Grant, aged 10, and lives at home with his mother and father. Nathan has been having difficulties with concentration at school, and his behaviour is also starting to deteriorate. He seems to be in a constant state of arousal and rarely sits still for more than a couple of minutes before becoming distracted and moving about in the classroom. He is impulsive and appears to be incapable of thinking things through before he acts. He constantly interferes with what his classmates are doing and often reacts angrily if challenged. The referral letter says that Nathan’s temper “goes from 0–60 in two seconds” and anyone who gets in his way risks being hit or kicked. He is unpopular with his classmates and does not seem to know how to interact with them in a positive way, although he seems to want to. Nathan is on the verge of permanent exclusion after hurting a male teacher who was trying to restrain him.

The initial assessment session with the paediatrician is attended by the whole nuclear family. The paediatrician notes several things about the family. Firstly, that Nathan is hard to engage, spending most of his time looking at his feet or gazing around him and shifting nervously in his chair. He says almost nothing, sitting close to his mother throughout. Secondly, he does not interact with his father at all, who sits slightly to one side of the room and also rarely makes eye contact. Mr Jones offers no information and appears uncomfortable with the situation, although he does respond with limited information when asked a direct question. Thirdly, Nathan’s brother Grant is a pleasant, talkative young boy who …