Takeaway
When patients show persistent inattention, disorganization, or poor response to anxiety treatment, consider the diagnosis of ADHD. A comprehensive, multidimensional assessment can uncover overlooked conditions and transform a patient’s life.
Lifelong Learning in Clinical Excellence | July 9, 2025 | 3 min read
By Joel Young, MD & Benjamin Young, MD, Wayne State University
Alex came to our clinic after years of accepting the difficulties she experienced as normal. Even though she always tries to pay attention, she finds herself daydreaming, making it impossible to focus on her work. She describes herself as “spacey” because she often forgets about plans or shows up late. Alex says things that don’t quite fit into conversations. Her friends constantly needle her that she “has no filter.”
Last year at her annual wellness visit, Alex completed an anxiety screener. She identified feeling restless, irritable, and worried. Her PCP diagnosed her with generalized anxiety disorder, and they agreed to trial an SSRI. Seven months into sertraline treatment, her anxiety had mildly improved, but her work performance remained subpar. Frustrated with her lack of clinical progress, her PCP encouraged a psychiatric evaluation.
One of the most common referrals to an outpatient psychiatric clinic is antidepressant failure. Alex’s psychiatric evaluation revealed longstanding inattention, distractibility, and impulsivity, which led to early academic underperformance. Alex disclosed that her most recent performance review was negative, and that her job was now in jeopardy. Additionally, Alex’s disorganization prevented her from keeping her apartment clean or her bills paid.
After a full assessment, Alex was diagnosed with ADHD, combined type. She did indeed have anxiety, but these symptoms were secondary to her persistent ADHD. Alex’s disorganization and impulsivity were ego-dystonic. We explained that her anxiety resulted from chronic feelings of being overwhelmed. Alex was referred for ADHD counseling, and a long-acting psychostimulant was prescribed. With treatment, she experienced a significant improvement in her daily functioning.
Although primary care is adept at evaluating anxiety and depression, screening for ADHD, another highly prevalent and debilitating psychiatric disorder, is overlooked. Were ADHD rating scales included in her wellness screening, Alex may have received earlier diagnosis and treatment.
Comprehensive assessment rooted in a biopsychosocial model helps us better understand the true source of the patient’s concerns. A comprehensive, multidimensional approach to diagnosis includes:
1. Conversations
Speaking with patients and gathering input from family gives insight into their childhood, family, and medical history. The clinical interview should establish symptom severity and functional impact on daily lives, relationships, and performance at school/work.
2. Rating scales
If initial conversations lead to suspected ADHD, validated self-report, clinician-rated, and observer-report questionnaires aid the next steps: Conners ADHD Rating Scales, ADHD Adult Self-Report Scale, and ADHD Symptom and Side Effect Tracking Scale (ASSET) are examples.
3. Evaluating comorbidities and reaching parsimony
Consulting the DSM-5 to identify potential comorbidities and rule out alternative diagnoses strengthens confidence that ADHD is the most parsimonious explanation for the patient’s behavioral pattern. Typically, ADHD symptoms are consistently observed across multiple settings and validated by independent observers such as parents and teachers. In Alex’s case, the diagnosis of ADHD accounted for her inattentiveness, impulsivity, and accompanying anxiety symptoms.
We advocate for comprehensive screenings that can help doctors and patients fully understand their symptoms and aid in differential diagnosis.
One such tool, MindMetrix, is a mental health assessment that offers a screening framework after the “Conversation” stage. Mindmetrix starts patients off with an adaptive questionnaire that narrows in on suspected conditions from over 60 potential disorders. Then, patients are guided through select validated rating scales for the hypothesized conditions, consistent with DSM-5 criteria. As their clinicians, we see the estimated likelihood that they have any of the flagged conditions (ADHD and others) that informs next steps in diagnosis.
An ADHD diagnosis can give patients like Alex an explanation for a lifetime of confusion and frustration, finally offering a solution instead of a bandage. Taking a broad, careful, and comprehensive approach allows us to build a complete picture of the patient that ultimately helps them get the care they need.
Learn more about the author here.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.