A screening score is a door, not a diagnosis. The note needs impairment, a history that this is not new, what else might be going on, and a plan that is more than “Adderall, see you in a month.”
Adult ADHD is having another internet week, the kind where people talk about shame and lost time as if that were the whole DSM. Some of the stories are the real illness. Some of them are depression, sleep apnea, a 2am cannabis habit, or a job that would melt anyone. My job is to tell those apart on paper, not to win a thread.
Impairment, not identity
Where it shows up. Work, driving, a degree they cannot finish, a kitchen they cannot keep. One setting is a maybe. Two is the usual bar. “I relate to the videos” is not impairment.
How long. Childhood report, old report cards, a parent who will take a call, or an honest “I don’t remember elementary school but I have been like this since I could drive.” Adult-onset everything is a different workup. Write which one you have.
What they already tried. Coaching, a stimulant in college, atomoxetine for six days, coffee. Incomplete trials get recorded as incomplete, the same way I want OCD trials recorded.
The differential belongs in the assessment
Sleep. Untreated apnea looks like inattention. If I did not ask, I do not get to write “ADHD, combined, start stimulant.”
Mood. Bipolar with a racing week is not a reason to send 30 days of amphetamine into the house. If I am unsure, the plan is a longer interview, not a compromise dose.
Substances. Alcohol, cannabis, the ketamine lozenges from last month. If the attention problem tracks the drug, treat that first or at least name the confound.
A new ADHD drug (centanafadine, Simtriyo) got an FDA approval this summer and still could not be dispensed while DEA scheduling sat open. Even when it exists on a shelf, there is no head-to-head against methylphenidate in the label. Do not write “start the new one” as if that were a completed thought. Write why not a known agent, or why a non-stimulant, or why you are waiting.
Grief can be true and still not finish the note
People are using the word grief for the years they think they lost. I believe them often. I still need a diagnosis and a monitoring plan. If a stimulant goes out, I write blood pressure, appetite, sleep, whether they can lock a bottle away from a teenager, and the first follow-up. If I am not prescribing today, I write what would make me willing.
Shame is not a reason to skip collateral. It is a reason to ask gently and still ask.
Questions I get
Is a self-report scale enough? No. It is part of the file. Combine it with the interview and, when you can, someone who knew them before they had a podcast vocabulary for this.
What if they only want a letter for accommodations? Then the letter has to match a diagnosis you actually made. A letter from a 15-minute video with no history is how those letters become worthless for everyone.
Do I document diversion risk? If I thought about it, yes: leftover pills, requests for early fills, a cousin with a similar script. If I didn’t think about it, I should have.