ADHD Testing Referral for Adults
For an adult patient seeking ADHD evaluation, you can initiate the assessment yourself in primary care, or refer to a psychiatrist or psychologist trained in adult ADHD diagnosis if you lack experience with this population. 1, 2
Primary Care Assessment is Appropriate
- Any psychiatrically trained physician using standard psychiatric assessment procedures can perform clinical evaluations for adult ADHD. 3
- Primary care clinicians can and should play a significant role in ADHD diagnosis and management, given the high prevalence and limited mental health resources. 2, 4
- The diagnostic process takes a comprehensive clinical interview but can begin with screening tools that require only 3-5 minutes. 4
When to Refer to a Specialist
Refer to a psychiatrist or psychologist experienced in adult ADHD when:
- You are not trained or experienced in diagnosing ADHD or its common comorbidities. 1
- Complex comorbid conditions are present (substance use disorders, mood disorders, anxiety disorders, personality disorders) that you cannot confidently manage. 1, 5
- The diagnostic picture is unclear or atypical, as ADHD symptoms overlap substantially with other psychiatric conditions. 2, 6
- The patient has been misdiagnosed previously with conditions like atypical depression, cyclothymia, or borderline personality disorder when ADHD may be the underlying issue. 3
Essential Diagnostic Components You Must Obtain
Document these specific elements regardless of who performs the evaluation:
- Childhood onset: Symptoms must have been present before age 12 years and persisted for at least 6 months. 1
- Multiple settings: Impairment must occur in at least two major settings (work, home, social relationships). 1
- Collateral information: Obtain information from family members, partners, or review old school records—adults with ADHD often underestimate their own symptoms. 1, 6
Recommended Assessment Tools
Use validated screening and diagnostic instruments:
- Adult ADHD Self-Report Scale (ASRS) for initial screening. 1
- Conners Adult ADHD Rating Scale (CAARS) for comprehensive symptom evaluation. 1, 2
- Weiss Functional Impairment Rating Scale-Self (WFIRS-S) to assess functional impairment in work, relationships, and daily management. 1
- Brown Attention-Deficit Disorder Scale for executive function deficits. 1
Critical Differential Diagnoses to Rule Out
Screen for these conditions that commonly mimic or co-occur with ADHD:
- Substance use disorders (current or past). 1, 5
- Mood disorders (bipolar disorder, major depression). 1, 5
- Anxiety disorders. 1, 5
- Personality disorders. 1, 5
- Sleep disorders (particularly narcolepsy). 1
- Learning disabilities and borderline intellectual functioning. 1
Common Diagnostic Pitfalls to Avoid
- Never rely solely on patient self-report—collateral information is essential as adults with ADHD underestimate their symptoms and impairments. 1
- Do not miss childhood onset—failure to establish symptoms before age 12 is a common error. 1
- Screen for substance use—overlooking current or past substance abuse leads to misdiagnosis. 1
- Be aware that mood lability and frustration intolerance are common in ADHD but not included in DSM-5 criteria, potentially leading to misdiagnosis as mood or personality disorders. 3, 6
Bottom Line on Referral Decision
If you are comfortable conducting psychiatric evaluations and using structured rating scales, you can diagnose adult ADHD in primary care. 3, 4 However, given that fewer than 20% of adults with ADHD are currently diagnosed or treated, and misdiagnosis is common, refer to a psychiatrist experienced in adult ADHD if you have any uncertainty about the diagnosis or management of comorbidities. 3, 5