Key moments, in order
The diagnosis tries to capture people with deficits in executive functioning. Executive function falls on a bell curve and ADHD is the very low percentile, so it is a spectrum, and every psychiatrist ends up with a different cutoff.
There is no bright line and no set standard for when to call it. It is a clinical judgment call, the diagnosis is a map and not the territory, and diagnoses are not lifelong.
Most diagnosis happens in a two-person reality, which makes it hard to pin down. That is why collateral and records help.
Know the life course of people most psychiatrists would agree have ADHD: problems with school and organization that persist across settings and continue through college and graduate school.
Lifelong trouble with self-direction (dropping out, many jobs and interests, unclear identity) most resembles a personality problem. That is not a claim of a personality disorder, and it is not a claim that the person lacks ADHD.
Inattention from a mood disorder usually brings no significant problems until at least adolescence. The patient who is zoned out at work and at home is often showing depressive withdrawal, and you do not hear the lifelong pattern in the history.
Substances and trauma show a stepwise drop in functioning and attention at an identifiable time.
Pretty bad kids are just as likely to have ADHD. Someone can have lots of personality problems and be even more likely to have mood symptoms too.
If you label ADHD as the primary problem, you tunnel yourself and the patient toward a lifetime of escalating stimulants.
The responsible psychiatrist names the comorbidities, even subthreshold ones, tells the patient and recommends how to manage them.
Almost everybody with ADHD functions better in a structured environment, which is why we sometimes see worsening in the less structured college environment.
Much of what social media calls ADHD symptoms, though present in many people with true ADHD, is better attributed to depressive disorders, trauma disorders and personality. Patients arrive believing ADHD explains their emotional dysregulation and relationship conflicts too.
Inattention is a symptom, like a cough. Having a cough does not mean you have cough disorder. Do not go straight for ADHD: rule in or out the other conditions you have evidence for.
Ask whether they have ever been treated with any prescription psychiatric medication, including ones they did not take.
Many clinicians notice things that do not add up but, out of kindness, avoid technical confrontations. Whenever you cannot form a picture of what happened, open more doors.
In a diagnostic interview the first purpose is information gathering. You are not trying to show the patient you are right and they are wrong; you are confirming or disconfirming a piece of history.
When it is unclear, say so: after one evaluation you are not exactly sure what they have, you hear some evidence of ADHD-type symptoms, and you want more visits.
While the assessment continues, push non-medication treatment and tell the patient there is no magic bullet.
Workbooks we recommend: Mastering Your Adult ADHD and the Executive Functioning Workbook for Adults. Better still is working with someone on real examples.
A concrete assignment: work in 30 to 35 minute chunks and schedule breaks of five to ten minutes, with no TikTok or clips during the break. That is the Pomodoro method.
If you become convinced after a couple more visits that there is an underlying ADHD problem, prescribe and see what happens. Stay skeptical of your diagnosis.
Prescribing at the first or second visit is fine, but only with enough evidence that the main problem is not a mood disorder, a personality disorder, a self-regulation problem or a mismatch between the person and their environment.
Neurodevelopmental disorders, except the specific learning disorders, are extreme types of normal variation in traits everyone has.
Only once mood, trauma and personality are sorted out do you move to structured or semi-structured ADHD questioning along the lines of the DIVA, not the self-report scales. The criteria were designed to be observed by parents and teachers, not reported by the person about themselves.
An ethical, thorough version of psychiatry needs more time, whatever the economy or the payer says.
When there is no indication, say it plainly: I understand you think the medication will help, but I don't see a medical indication today, so I'm not going to prescribe anything.
Even for the most biological disorders, treatment works over at least two or three months. A major effect within a few weeks, or a stimulant that seems to stop working and need a higher dose after a few weeks, is the drug effect. Do not fall for that trap.
Save the last 15 minutes or so of the intake for discussing your case formulation. Patients notice you are not a reductionistic doctor.
With at least 60 to 70 percent confidence in a neurodevelopmental ADHD-type disorder, one of us goes straight to atomoxetine. With possible depression, no bipolar disorder and some ADHD features the patient agrees with, try bupropion.
With autistic traits but not ADHD, sleep-wake dysregulation is common; reach for something not habit-forming.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.