Mary is a 30 year old woman with asthma who takes a daily steroid inhaler. At your recent PCP visit together, she mentions that she is stressed at work: her boss told her she needs to be more organized and less distracted. She has friends with ADHD (attention deficit hyperactivity disorder) and wonders if she might have ADHD, too.
How do you assess an adult patient who is concerned about undiagnosed ADHD?
A patient like Mary, with several current symptoms of ADHD, does not necessarily have a diagnosis of ADHD. Diagnosing ADHD in an adult involves understanding a patient’s developmental history, current symptoms, and degree of current functional impairment. Does your patient’s experience represent a continuation of symptoms from childhood (which would fit the ADHD diagnosis) or are their symptoms of inattentiveness and difficulty focusing new and present only at work (which would not fit an ADHD diagnosis)? (Huang, 2020) Only 17% of children with ADHD continue to meet criteria for ADHD as adults (Caye, 2016).
One must also rule out other common causes of inattention and executive dysfunction, including, among others, mood and anxiety disorders, PTSD, substance use disorders, and schizophrenia spectrum disorders. ADHD is a clinical diagnosis based on clinical history. What follows is an overview of what to cover in a diagnostic interview for ADHD. It aims to help you get started in evaluating inattention as a symptom, instead of immediately referring adult patients to psychiatry.
Start with open ended questions:What have you noticed about your behavior? What have other people noticed about your behavior? When did these behavioral challenges start? (CHADD, 2017) What is happening now that made you seek help today? (Mierau, 2025)
| Mary says that she brought this topic up today because of the negative feedback she received at work. She has always identified as a distracted person. As a little girl, she was known for being unable to sit still. As a teenager, she was considered flaky. She is a physical education teacher and does well on the main portion of her job – running around with teenagers. She has had a hard time focusing on paperwork. She is constantly moving from one task to the next, and it is hard to actually complete the paperwork in a timely fashion. She has a new supervisor who tracks paperwork completion much more closely than her previous supervisor. |
Ask about childhood and school performance:
ADHD is a developmental disorder that begins in childhood, before age 12, according to the DSM-5. Ask the patient to elaborate on their experience as a child, specifically in school and with friends. How was school for you? What were your grades like? Did you ever need to repeat a grade? Were you ever evaluated for or diagnosed with a learning disability? Did you ever have an individualized educational program (IEP)? Did you ever get in trouble in school or experience disciplinary action? How were things socially for you as a child? (Huang, 2020)
| Mary had a C average in school. She repeated 4th grade and became the oldest person in her grade. She was beloved by classmates for her sense of humor and high energy. She graduated from high school and became a substitute teacher at her local high school. She completed her teaching credentials over 7 years in a distance learning program and has taught physical education for the last 5 years. |
Ask about current symptoms of ADHD:
According to the DSM-5, adults with ADHD must have 5 or more symptoms in the inattentive and/or hyperactive/impulsive domains. Hyperactive/impulsive symptoms are more common in children with ADHD than in adults. The symptoms should begin before age 12, be present in 2 or more settings, and cause impairment with social, academic, or work performance (Posner, 2020).
I often pull up the DSM-5 criteria and check off the associated criteria while asking the broader questions listed below.
Questions to ask for the inattention domain:
How does your inattention impact your life? What challenges does it cause at work? In your personal life? What happens when you are given a task to do? What does it look like when you go grocery shopping? How do you keep organized? How do you manage the physical items in your life, like your keys, wallet and phone?
Domain of Inattention (Posner, 2020)
Often cannot give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
Often has trouble holding attention on tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and does not finish schoolwork, chores,or duties in the workplace (eg, loses focus, or is side-tracked)
Often has trouble organising tasks and activities
Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a longperiod of time (such as schoolwork or homework)
Often loses things necessary for tasks and activities (eg, school materials, pencils,books, tools, wallets, keys, paperwork, eyeglasses, and mobile telephones)
Is often easily distractedIs often forgetful in daily activities
Questions to ask for the hyperactivity and impulsivity domain:
What do you like to do for fun? Do you ever have trouble in conversations, either 1 on 1 or in groups? How would friends describe your behavior in social gatherings?
Domain of Hyperactivity and impulsivity (Posner, 2020)
Often fidgets with or taps hands or feet, or squirms in seat
Often leaves seat in situations when remaining seated is expected
Often runs about or climbs in situations where it is not appropriate (adolescents oradults might be limited to feeling restless)
Often unable to play or take part in leisure activities quietlyIs often “on the go” or acting as if “driven by a motor”
Often talks excessively
Often blurts out an answer before a question has been completed
Often has trouble waiting their turn
Often interrupts or intrudes on others (eg, conversations or games)
Many of the symptoms of ADHD can be observed in your interactions with the patient, particularly those in the hyperactivity / impulsivity domain. Is the patient fidgety, talking excessively, or struggling to wait their turn when talking with you? Do they arrive 15 minutes late for every appointment, forget their phone in the exam room when they leave, lose their train of thought when a person walks by the window, or seem to have a hard time remembering what you have discussed with them?
| Mary says that the administrative parts of her job are hard for her. She is supposed to fill out paperwork after each session but is weeks behind. She loses things constantly, in particular her cellphone. She has yet to take on managing her own finances; her parents check her bank account and pay her phone bill and utilities. She is embarrassed by this but also knows that she would not do it in a timely way otherwise. Mary describes herself as very energetic. She works with teenagers, so this degree of energy is helpful. Her friends describe her as loud, very chatty, and sometimes intrusive, with a tendency to interrupt other people’s conversations, and very chatty. She is “hilarious” so it works, but she knows that her friends don’t turn to her in difficult situations. Mary is constantly jiggling both her legs during her appointments with you. She is funny and it is hard to get a word in sometimes. She leaves her after visit summary in the exam room and comes back for it 10 minutes later. |
Ask for permission to obtain collateral:
Speaking to a patient’s partner, friend, or family member is an essential part of the ADHD diagnostic interview (CHADD, 2017). Ask for permission to speak with someone who knows the patient well, preferably someone who knew them as a child.
| You call Mary’s father after the visit. He confirms the description Mary has given you of herself and her behavior. He notes that she always struggled in school, including elementary school, but excelled in sports and drama. He felt like Mary had other strengths, and that school didn’t need to be for everyone. He also struggled in school. He now sees how her difficulty with organizing herself and finishing tasks is having a substantial negative impact on her life. He confirms that Mary does not have trouble with drugs or alcohol. |
Evaluate for coexisting conditions:
ADHD co-occurs with other mental health diagnoses, most frequently substance use disorders, anxiety, and mood disorders. Any adult presenting with problems with focus or concentration should be carefully evaluated for coexisting and alternative diagnoses, specifically depression, anxiety, PTSD, and substance use. Patients should be asked about their previous experience taking prescription stimulants (Adderall, Vyvanse, Ritalin, etc.): what they have taken (including doses), what it did for them, and any side effects.
Some medical conditions can mimic the symptoms of ADHD, in particular thyroid and sleep disorders, hormonal shifts around menopause, and progressive neurologic disease, including brain injury, stroke, and dementia (Volkow, 2013). In terms of a sleep history, ask specifically about how much sleep your patient is getting, and about trouble falling asleep, restless leg symptoms, nighttime awakenings, snoring, and nightmares. Medications that may also affect attention include caffeine and other prescribed or unprescribed stimulants, nicotine, steroids, antihistamines, anticholinergics, benzodiazepines, sleep aids, opioids, anticonvulsants, muscle relaxants, and any nonprescribed over the counter medications (Huang, 2020).
| Mary has negative screenings of PHQ-2 for depression, GAD-7 for anxiety, and PC-PTSD5 for PTSD. She is only taking her prescribed corticosteroid inhaler. She has never taken Ritalin or Adderall or another stimulant. She avoids caffeine products and alcohol. She has never smoked tobacco. She takes marijuana gummies with friends about once a month. She sleeps 7 hours a night, denies problems with falling or staying asleep, and feels rested in the morning. Her boyfriend has never commented on snoring or unusual movements in her sleep. |
Diagnose likely ADHD:
ADHD presents differently in adults than in children. Inattentive symptoms often predominate in adults. The consequences of these symptoms include employment, financial, and marital problems including frequent job changes, and increased rates of separation, divorce, and car accidents (Volkow, 2013). Furthermore, the impact of ADHD can vary in different settings (Posner 2020). Patients with ADHD may be able to maintain a healthy partnership in their personal life but not maintain a consistent job, or they may find a job that fits well with their strengths but have significant problems managing the administrative tasks in their life (taxes, insurance, bills, etc.). As Posner notes, “All evidence confirms that ADHD is best understood as the extreme end of a continuum and that people with ADHD differ from those without ADHD by degree rather than in kind” (Posner, 2020).
| Per your interview, Mary meets over 5 criteria in both inattention and hyperactivity/impulsivity domains. Her description and her father confirm that she has demonstrated these behaviors since childhood. Her behaviors are present in multiple contexts and have had negative consequences for her professionally (poor performance review, not completely essential work tasks), socially (not a reliable friend), and financially (reliant on her parents for paying bills). |
Additional testing?
No additional lab or imaging testing is needed to diagnose ADHD. I routinely check a urine drug screen before starting a stimulant medication. The ASRS is a patient questionnaire that can be helpful in ruling out ADHD (negative predictive value is 98% (Taylor, 2011)); however, it is not necessary to use this questionnaire if you are performing a thorough diagnostic interview. Neuropsychiatric formal testing is also not needed to make the diagnosis (Huang, 2020).
Initiate treatment and/or refer to a psychiatrist:
You have brought Mary one step closer to a diagnosis and possible treatment. Treating ADHD can help improve a patient’s physical health through increased self-monitoring and improved management of chronic health conditions (Asherson, 2022). Diagnosing ADHD can be difficult and time-consuming – more akin to the complexity of diagnosing bipolar disorder than alcohol use disorder. Depending on your experience and the clarity gained during this conversation, you can consider starting medication for a primary care patient who clearly meets criteria for ADHD based on your diagnostic interview. If you are unsure or if there are multiple comorbidities that make the diagnosis complex, you can also refer to a psychiatrist to review your diagnostic interview and start medication if warranted.
Look out for a future PsychSnap on starting medications for ADHD.
Key Points
1) Problems with focus, concentration, or inattention are not always due to ADHD.
2) Diagnosing ADHD in an adult involves both ruling-in ADHD by developmental history, current symptoms and functional impairment in multiple contexts and ruling-out other common causes of inattention.
3) PCPs can diagnose ADHD; the process takes time and requires a thorough psychiatric interview and collateral information. If there are significant comorbidities or diagnostic uncertainty, refer to a psychiatrist.
References
Asherson, P., et al. (2022). Mainstreaming adult ADHD into primary care in the UK: Guidance, practice, and best practice recommendations. BMC Psychiatry, 22(1), 640.
Caye, A., et al. (2016). Attention-Deficit/Hyperactivity Disorder Trajectories From Childhood to Young Adulthood: Evidence From a Birth Cohort Supporting a Late-Onset Syndrome. JAMA Psychiatry, 73(7), 705.
CHADD’s National Resource Center on ADHD. (2017). Diagnosis of ADHD in Adults.
Huang, H., et al. (2020). Approach to Evaluating and Managing Adult Attention-Deficit/Hyperactivity Disorder in Primary Care. Harvard Review of Psychiatry, 28(2), 100–106.
Mierau, S. B. (2025). Do I Have ADHD? Diagnosis of ADHD in Adulthood and Its Mimics in the Neurology Clinic. Neurology Clinical Practice, 15(1), e200433.
Posner, J., et al. (2020). Attention-deficit hyperactivity disorder. The Lancet, 395(10222), 450–462.
Taylor, A., et al. (2011). Scales for the identification of adults with attention deficit hyperactivity disorder (ADHD): A systematic review. Research in Developmental Disabilities, 32(3),
924–938.
Volkow, N. D., & Swanson, J. M. (2013). Adult Attention Deficit–Hyperactivity Disorder. New England Journal of Medicine, 369(20), 1935–1944.