Not All Inattention Is ADHD: A Practical Framework for PCPs

This episode offers a conceptual and practical framework for starting ADHD assessments in primary care and other outpatient settings, distinguishing ADHD from other causes of attentional complaints, and avoiding both over- and under-diagnosis.

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Conceptual Foundations

ADHD in adults is a clinical diagnosis, not one that requires formal neuropsychiatric testing (though such testing may be quite helpful in complex cases).

But not all inattention is ADHD. Today’s environment, one that is fast-paced, tech-saturated, and hyperproductive, has created conditions where even neurotypical adults feel chronically distracted. This can lead to over-pathologizing normal struggles, particularly among those self-diagnosing based on social media content.

The episode also addresses the controversial notion of adult-onset ADHD — symptoms that appear without any childhood history. While some researchers argue it may exist in rare cases, most studies suggest these presentations reflect other issues such as depression, anxiety, or burnout.

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Key Points Covered

• Cultural Influences: Social media, increased mental health awareness, and stimulant familiarity have contributed to both destigmatization of ADHD as well as self-diagnosis
• The Attention Economy: Our technology-driven world actively undermines focus, compounding subjective feelings of inattention
• Clinical Red Flags: New-onset attentional complaints without any childhood symptoms should prompt exploration of alternate diagnoses
• Stimulant Seeking: The performance-enhancing effects of stimulants raise the risk of misreporting or exaggeration, particularly in academic and professional settings
• No Rush to Diagnose: ADHD isn’t an emergency diagnosis; you can and should space the process across multiple visits when needed

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Differential Diagnosis

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Tools for Assessment

Two screeners are especially well-suited for use in primary care. You can find links to PDFs of them above:

• ADHD Self-Report Scale (ASRS)
  • Focuses on current symptoms of ADHD. Can be completed in-office or at home. Useful first-pass screener for present-day functioning.
• Wender Utah Rating Scale (WURS)
  • Assesses retrospective childhood symptoms, which is essential given that a diagnosis of ADHD typically requires symptom onset before age 12.

When used together, these screeners offer a way to cross-reference past and present functioning and begin building a diagnostic picture.

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A Primary Care-Friendly Workflow

First Visit:

• Explore the patient’s attentional concerns
• Ask about childhood functioning
• Provide the ASRS and WURS to complete

Second Visit:

• Review screener results
• Dive deeper into symptom patterns, onset, and functional impairment
• Consider whether the clinical picture is consistent with ADHD or suggests alternative explanations

ADHD diagnosis and treatment don’t need to happen in one visit. Taking time improves diagnostic confidence and helps maintain a thoughtful, measured approach, especially in a time of growing stimulant use and public interest in mental health.