College student with chronic inattention, procrastination, fidgeting, excessive phone use, social anxiety and panic attacks; ASRS‑v1.1 Part A ≥4/6 and Part B ≥6/12 – what is the likely diagnosis and appropriate evaluation and treatment plan?

Diagnosis: ADHD, Predominantly Inattentive Presentation with Comorbid Social Anxiety and Panic Disorder

This college student meets full DSM-5 criteria for ADHD, predominantly inattentive presentation, and requires initiation of stimulant medication combined with behavioral therapy, academic accommodations through disability services, and targeted treatment for comorbid anxiety disorders. 1, 2

Diagnostic Confirmation

ADHD Diagnosis is Established

• The ASRS-v1.1 Part A is positive (5/6 items endorsed as "often" or "very often"), which triggers comprehensive diagnostic evaluation per screening guidelines. 2
• DSM-5 criteria are met: At least 5 inattentive symptoms present (difficulty organizing tasks, avoiding sustained mental effort, careless mistakes, difficulty sustaining attention, easily distracted, forgetful, difficulty following through on tasks), with clear functional impairment documented in multiple settings (home, work, school, relationships). 1, 2
• Childhood onset is documented: The patient reports not needing to try as hard when younger, ESL services in elementary school, reading preparation program through junior year of high school, and chronic procrastination/homework completion difficulties—all establishing symptom presence before age 12. 1, 2
• Pervasive impairment across settings: Academic struggles (difficulty keeping up with peers, careless mistakes on exams, challenges with non-major classes), work difficulties (forgetting tasks, needing repeated clarification), home dysfunction (laundry piling up for weeks, inability to complete cleaning), and relationship problems (spacing out, others repeating themselves). 1, 2

Comorbid Conditions Identified

• Social anxiety disorder is present: Fear of humiliation in social situations, worry about professors' opinions, anxiety about contributing to projects, avoidance behavior (staying in room during holiday to avoid greeting people), and panic symptoms (sweating, trembling, chest discomfort, fear of losing control). 2, 3
• Panic disorder with history of panic attacks in 2022, though patient reports improved coping strategies. 2
• Depression is ruled out: Patient denies depressed mood, anhedonia, suicidal ideation, reports normal energy and good motivation for degree. 2

Critical Differential Diagnoses Excluded

• Substance use does not explain symptoms: No evidence of marijuana, alcohol, or stimulant use that would mimic ADHD presentation. 2
• Sleep disorder unlikely primary cause: While sleep is suboptimal (6 hours nightly), the chronic nature of symptoms since childhood and pervasive functional impairment across all settings make primary sleep disorder unlikely. 2
• Symptoms are not better explained by anxiety alone: The inattentive symptoms predate college-related anxiety, were present in childhood, and persist across non-anxiety-provoking situations. 2

Treatment Plan

First-Line Pharmacotherapy: Stimulant Medication

Initiate methylphenidate or amphetamine formulation as first-line treatment, with titration to maximum benefit and minimum adverse effects. 1, 2, 4

• Stimulants are first-line despite comorbid anxiety: Approximately 60-70% of adults show moderate-to-marked improvement with stimulants when properly titrated. 1, 2
• Treatment of ADHD may resolve comorbid anxiety: Evidence suggests that treating ADHD can lead to improvement in both attentional deficits and anxiety symptoms, particularly when social anxiety developed secondary to ADHD-related social failures. 1, 5, 3
• Titration strategy: Start at lower dose and increase systematically to achieve optimal symptom control across academic demands, including consideration of late-afternoon dosing for studying and evening classes. 1, 6
• Expected outcome: More than 70% respond to stimulants when properly titrated across full dose range. 6

Alternative if Stimulants Not Tolerated

• Atomoxetine, viloxazine, or bupropion should be considered if stimulants cannot be tolerated or if anxiety worsens significantly with stimulant treatment. 2, 7, 4
• Atomoxetine is FDA-approved for adult ADHD and may be particularly appropriate given comorbid anxiety. 7

Behavioral and Psychosocial Interventions

Combined medication plus psychotherapy is more effective than either alone and should be implemented concurrently. 1, 2, 6

• Cognitive-behavioral therapy (CBT) targeting both ADHD-related executive function deficits and anxiety symptoms. 2, 8
• Psychoeducation about ADHD, its impact on functioning, and strategies for symptom management. 2
• Behavioral strategies: Implementation of organizational systems, breaking tasks into smaller components, using external reminders and timers, structured study environments with noise-cancelling headphones (already utilizing). 1, 6
• Executive function training focused on task initiation, planning, and time management. 6

Academic Accommodations Through University Disability Services

This student qualifies for Section 504 accommodations and should immediately register with university disability services. 1, 6

Recommended Accommodations:

• Extended time for exams and assignments (typically time-and-a-half to double time). 1, 6
• Reduced-distraction testing environment (separate room for exams). 1, 6
• Access to instructor notes or permission to record lectures to compensate for attention lapses during class. 6
• Flexible deadlines with structured check-ins to prevent last-minute completion. 6
• Preferred seating (front of classroom to minimize distractions). 1, 6
• Permission for fidget tools during class and exams (already self-implementing). 6
• Academic coaching or tutoring services for one-on-one support with organization and study skills. 6

Addressing Comorbid Anxiety

• Monitor anxiety response to stimulant treatment: In many cases, treating ADHD improves social anxiety that developed secondary to ADHD-related social failures and academic struggles. 1, 5, 3
• If anxiety persists or worsens: Consider adding SSRI or switching to atomoxetine as primary ADHD medication. 2, 4
• CBT specifically targeting social anxiety if symptoms remain impairing after ADHD treatment optimization. 2, 8

Behavioral Modifications for Phone Use

• Excessive screen time (5 hours daily scrolling) represents avoidance behavior and contributes to task avoidance; implement structured limits using app timers and scheduled phone-free study blocks. 2
• This behavior pattern is consistent with ADHD-related difficulty with self-regulation and should improve with treatment. 2

Monitoring and Follow-Up

Initial Phase (First 3 Months)

• Weekly to biweekly visits during medication titration to assess symptom response, side effects (appetite, sleep, anxiety, heart rate, blood pressure), and functional improvement. 1, 2
• Collateral information from academic performance (exam scores, assignment completion) to guide dose adjustments. 1, 2
• Screen for stimulant misuse or diversion using clinical interview; document appropriate use. 2, 4

Maintenance Phase

• Monthly to quarterly visits once stable dose achieved, with ongoing assessment of academic functioning, anxiety symptoms, and medication adherence. 2, 6
• Continuous monitoring for emerging comorbidities, particularly depression and substance use. 2
• Coordinate with university disability services to ensure accommodations are implemented and effective. 6

Common Pitfalls to Avoid

• Do not delay ADHD treatment due to comorbid anxiety: Treating ADHD first often improves both conditions, and delaying treatment perpetuates academic and functional impairment. 1, 5, 3
• Do not rely solely on accommodations without medication: While accommodations are essential, they do not address core neurobiological deficits; combined treatment is most effective. 1, 6
• Do not undertitrate stimulants: Suboptimal dosing produces positive but inadequate effects; systematic titration to maximum benefit is required. 1, 6
• Do not attribute all symptoms to anxiety: The childhood onset, pervasive nature across settings, and specific pattern of inattentive symptoms clearly indicate ADHD as primary diagnosis. 2, 3
• Do not overlook sleep optimization: While not the primary cause, improving sleep hygiene (earlier bedtime, consistent schedule) will enhance treatment response. 2