One-liner#

Diagnose adult ADHD using validated screening tools and clinical criteria requiring childhood onset, initiate stimulant or non-stimulant treatment with appropriate monitoring, and recognize when to refer for complex cases.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• ADHD itself is not an emergency

Do NOT prescribe stimulants if:

• Active substance use disorder (especially stimulants, cocaine)
• Uncontrolled hypertension or significant cardiovascular disease
• History of psychosis or current psychotic symptoms
• Severe anxiety (stimulants may worsen)
• Suspected malingering or drug-seeking behavior

Refer to psychiatry instead of managing in primary care if:

• Comorbid bipolar disorder
• History of stimulant misuse
• Complex psychiatric comorbidity
• Diagnostic uncertainty

Key history#

DSM-5 criteria for ADHD:

• ≥5 symptoms of inattention AND/OR ≥5 symptoms of hyperactivity-impulsivity
• Symptoms present before age 12 (CRITICAL—must have childhood onset)
• Symptoms present in 2+ settings (work, home, relationships)
• Clear evidence of functional impairment
• Not better explained by another mental disorder

Inattention symptoms:

• Fails to give close attention to details; careless mistakes
• Difficulty sustaining attention
• Does not seem to listen when spoken to directly
• Does not follow through on instructions; fails to finish tasks
• Difficulty organizing tasks and activities
• Avoids tasks requiring sustained mental effort
• Loses things necessary for tasks
• Easily distracted by extraneous stimuli
• Forgetful in daily activities

Hyperactivity-impulsivity symptoms:

• Fidgets or squirms
• Leaves seat when remaining seated expected
• Runs about or climbs inappropriately (in adults: restlessness)
• Unable to engage in leisure activities quietly
• “On the go” or “driven by a motor”
• Talks excessively
• Blurts out answers before question completed
• Difficulty waiting turn
• Interrupts or intrudes on others

Presentations:

• Predominantly inattentive (most common in adults, especially women)
• Predominantly hyperactive-impulsive
• Combined

Screening tools:

• Adult ADHD Self-Report Scale (ASRS-v1.1): 6-item screener; ≥4 positive = likely ADHD
• Full 18-item ASRS for comprehensive assessment
• Conners Adult ADHD Rating Scale (CAARS)

CRITICAL: Establish childhood onset:

• “Did you have these problems as a child?”
• “What were your report cards like? Did teachers comment on attention or behavior?”
• “Were you ever evaluated for ADHD as a child?”
• Collateral from parents, old report cards, or childhood records if available
• If no evidence of childhood symptoms → diagnosis is NOT ADHD

Functional impairment:

• Work: difficulty completing tasks, missing deadlines, job instability
• Relationships: not listening, forgetting important things, impulsivity
• Finances: impulsive spending, forgetting bills
• Driving: accidents, tickets
• Education: underachievement relative to ability

Rule out other causes:

• Sleep disorders (sleep deprivation mimics ADHD)
• Depression (concentration problems)
• Anxiety (difficulty focusing due to worry)
• Substance use (stimulants, cannabis)
• Thyroid disorders
• Medical conditions (anemia, chronic fatigue)

Comorbidities (very common):

• Anxiety (30-50%)
• Depression (30-50%)
• Substance use disorders (higher risk)
• Learning disabilities
• Sleep disorders

Substance use screen:

• MUST screen before prescribing stimulants
• Active stimulant or cocaine use = do not prescribe stimulants
• History of stimulant misuse = consider non-stimulant or psychiatry referral
• Stable recovery from other substances = can consider stimulants with monitoring

Focused exam#

Vital signs:

• Blood pressure (baseline before stimulants)
• Heart rate
• Weight (stimulants can cause weight loss)

Cardiovascular:

• Listen for murmurs, irregular rhythm
• Personal or family history of sudden cardiac death, arrhythmias, cardiomyopathy

Mental status:

• Observe for restlessness, fidgeting, distractibility
• Assess mood (rule out depression, mania)
• Assess for anxiety
• Rule out psychotic symptoms

General:

• Signs of substance use
• Thyroid exam if symptoms suggest

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Baseline before starting stimulants:

Consider based on presentation:

When NOT to order extensive workup:

• Classic ADHD presentation with clear childhood onset
• No cardiac risk factors
• Routine ECG not required in healthy adults without cardiac history

Collateral information (strongly recommended):

• Childhood report cards or records
• Parent or sibling report of childhood symptoms
• Spouse/partner report of current symptoms
• Prior psychological testing if available

Initial management#

Confirm diagnosis before treatment:

• Childhood onset documented
• Symptoms in multiple settings
• Functional impairment
• Other causes ruled out

Treatment options:

1. Stimulants (first-line for most adults)
2. Non-stimulants (if stimulants contraindicated or not tolerated)
3. Behavioral strategies (helpful adjunct but rarely sufficient alone in adults)

Stimulant selection:

• Methylphenidate-based vs amphetamine-based: similar efficacy; individual response varies
• Start with one; if inadequate response or intolerable side effects, try the other class
• Long-acting formulations preferred (better coverage, less abuse potential)

Management by diagnosis#

Adult ADHD#

Education:

• ADHD is a neurodevelopmental disorder, not a character flaw
• Medications are effective for most people
• Stimulants work immediately but need dose optimization
• Behavioral strategies complement medication
• Treatment is often long-term

Treatment:

First-line: Stimulants

Second-line: Non-stimulants

Choosing a medication:

• First-line: long-acting stimulant (lisdexamfetamine or methylphenidate ER)
• If one stimulant class fails: try the other class
• If stimulants contraindicated: atomoxetine or viloxazine
• If comorbid anxiety: consider atomoxetine or add anxiety treatment
• If comorbid depression: bupropion may help both
• If substance use history: non-stimulant preferred; or lisdexamfetamine (lower abuse potential)

Stimulant side effects:

• Decreased appetite, weight loss
• Insomnia (take earlier in day; avoid late dosing)
• Increased BP and HR (usually modest)
• Anxiety, irritability
• Headache
• Rare: psychosis, mania (discontinue immediately)

Controlled substance prescribing:

• Schedule II (stimulants): no refills; new prescription each month
• Check PDMP before prescribing and periodically
• Document indication, response, and monitoring
• Consider treatment agreement for stimulants
• Pill counts if diversion suspected

Drug shortage considerations:

• Stimulant shortages are common; have backup plan
• If usual medication unavailable: can switch within class (e.g., one methylphenidate ER to another)
• Switching between amphetamine and methylphenidate classes is reasonable
• Short-acting formulations may be more available
• Non-stimulants (atomoxetine) rarely in shortage

Pregnancy:

• Limited safety data for stimulants in pregnancy
• Generally discontinue stimulants if possible during pregnancy
• If ADHD severely impairing: discuss risks/benefits; methylphenidate may have more safety data than amphetamines
• Non-stimulants: atomoxetine limited data; avoid if possible
• Refer to psychiatry and MFM for shared decision-making

Follow-up: 2-4 weeks after starting; then monthly until stable; then every 3-6 months.

ADHD with comorbid anxiety#

Education:

• Very common combination
• Stimulants can worsen anxiety in some patients
• May need to treat both conditions

Treatment:

• Option 1: Start SSRI for anxiety first; add stimulant once anxiety controlled
• Option 2: Start atomoxetine (treats both, no anxiety worsening)
• Option 3: Start low-dose stimulant with close monitoring; add SSRI if anxiety worsens
• Avoid high-dose stimulants if anxiety prominent

Follow-up: Close monitoring; 2 weeks initially.

ADHD with comorbid depression#

Education:

• Common combination
• Treating ADHD may improve some depressive symptoms
• May need treatment for both

Treatment:

• If depression severe: treat depression first
• If depression mild-moderate: can start ADHD treatment; monitor mood
• Bupropion can help both (modest ADHD effect)
• Atomoxetine may help both

Follow-up: Monitor mood closely; PHQ-9 at each visit.

Follow-up#

Initial:

• 2-4 weeks after starting medication
• Assess response, side effects, vital signs
• Adjust dose as needed

Ongoing:

• Monthly until stable dose achieved
• Then every 3-6 months
• Check BP, HR, weight at each visit
• PDMP check periodically

At each visit:

• Symptom response (ASRS or clinical assessment)
• Side effects
• Vital signs (BP, HR)
• Weight
• Sleep quality
• Mood (screen for depression, anxiety, mania)
• Substance use
• Medication adherence and supply

Return precautions:

• Chest pain, palpitations, shortness of breath
• Severe anxiety or mood changes
• Psychotic symptoms (hallucinations, paranoia)
• Significant weight loss
• Insomnia not improving with timing adjustments

When to refer to psychiatry:

• Comorbid bipolar disorder
• Treatment-resistant ADHD (failed 2+ medications)
• Complex comorbidities
• History of stimulant misuse
• Diagnostic uncertainty

Patient instructions#

• ADHD is a real medical condition that affects how your brain regulates attention and impulses. It’s not a character flaw.
• Medication helps most people with ADHD focus better and be more organized. It works right away, but we may need to adjust the dose.
• Take your medication in the morning. Taking it too late can cause trouble sleeping.
• Common side effects include decreased appetite and trouble sleeping. These often improve over time.
• Do not share your medication with anyone. It’s a controlled substance and sharing is illegal.
• Keep all appointments so we can monitor your blood pressure, heart rate, and how the medication is working.
• Call us if you have chest pain, racing heart, severe anxiety, or feel like you’re “not yourself.”

Smartphrase snippets#

.ADHDEVAL Adult ADHD evaluation. ASRS screening score [X]. Patient reports [inattention / hyperactivity-impulsivity / combined] symptoms since childhood. [Collateral obtained from: parent/spouse/records]. Functional impairment in [work/relationships/finances]. Ruled out: depression (PHQ-9 [X]), anxiety (GAD-7 [X]), sleep disorder, substance use (UDS negative). Meets DSM-5 criteria for ADHD, [predominantly inattentive / combined] presentation. Plan: Start [medication, dose]. Baseline BP [X], HR [X], weight [X]. Discussed side effects, controlled substance responsibilities. Follow-up in 2-4 weeks.

.ADHDFOLLOWUP ADHD follow-up on [medication, dose]. Patient reports [improved focus / partial response / no improvement]. Side effects: [none / decreased appetite / insomnia / other]. BP [X], HR [X], weight [X]. PDMP checked: [consistent with prescribed]. Plan: [continue current dose / increase to X / switch to Y / add Z]. Follow-up in [4 weeks / 3 months].

.ADHDSTIMULANTDECLINE Patient requesting stimulant medication for ADHD. After evaluation, [unable to confirm childhood onset / active substance use / significant cardiac history / other concern]. Discussed that stimulants are not appropriate at this time. Offered [non-stimulant medication / psychiatry referral / treatment of underlying condition]. Patient [agrees / declines].

Related pages#

• Adult ADHD (problem) — comprehensive ongoing management of adult ADHD
• Depression — commonly comorbid; can mimic ADHD
• Anxiety — commonly comorbid; stimulants may worsen
• Substance use — screen before prescribing stimulants
• Insomnia — sleep deprivation mimics ADHD; stimulants can cause insomnia