ADHD Diagnostic Cheat Sheet for Therapists 📝

The assessment is a two-part process: a structured checklist based on the DSM-5 criteria and a deep dive into supplementary, non-DSM-5 clinical experiences.

Part 1: The Formal Diagnostic Framework (DSM-5 via ASRS)

Tool: Adult ADHD Self-Report Scale (ASRS) Checklist.
Purpose: A standardized screening tool based on DSM-5 criteria.
Scoring: Comprises two parts:

Part A (Questions 1-6): Most predictive symptoms. A score of ≥4 is highly indicative of ADHD.
Part B (Questions 7-18): Supplementary symptoms that provide additional evidence.

Key DSM-5 Criteria for Diagnosis (Must Be Met):

A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.
Several symptoms were present before age 12.
Symptoms are present in two or more settings (e.g., home, work, school).
Clear evidence that symptoms interfere with social, academic, or occupational functioning.
Symptoms are not better explained by another mental disorder (e.g., Anxiety, Autism).

Inattention Symptoms (Core Criteria)

ASRS-Based Question (Examples)	Clinical Feature
Trouble wrapping up final details of a project once the challenging parts are done.	Difficulty with completion and final details.
Difficulty getting things in order when a task requires organization.	Organizational challenges.
Problems remembering appointments or obligations.	Memory deficits for future tasks.
Avoid or delay getting started on a task that requires a lot of thought.	Task initiation difficulty/procrastination.
Make careless mistakes on boring or difficult projects.	Carelessness due to under-stimulation or difficulty.
Difficulty keeping attention on boring or repetitive work.	Sustained attention challenges, especially with low interest.
Trouble concentrating on what people say, even when they are speaking directly.	Listening/Concentration impairment.
Misplace or have difficulty finding things at work or at home.	Disorganization/Forgetfulness (Out of sight, out of mind).
Distracted by activity or noise around you.	External distractibility.

Hyperactivity and Impulsivity Symptoms (Core Criteria)

ASRS-Based Question (Examples)	Clinical Feature
Fidget or squirm with hands or feet when you have to sit down for a long time.	Fidgeting/Restlessness.
Feel overly active and compelled to do things like you are driven by a motor.	Subjective feeling of being "on the go".
Leave your seat in meetings or other situations in which you're expected to remain seated.	Inability to remain seated.
Feel restless or fidgety.	Internal restlessness (often masked).
Difficulty unwinding and relaxing when you have time to yourself.	Inability to quiet the mind without external focus (e.g., screen time).
Find yourself talking too much in social situations.	Excessive talking.
Find yourself finishing the sentences of people you're talking to.	Impulsive speech/Interrupting thoughts.
Trouble waiting your turn in situations when turn-taking is required.	Impatience/Turn-taking difficulty.
Interrupt others when they are busy.	Verbal impulsivity/Interrupting other

Crucial Clinical Consideration: Account for Masking

Always ask: "What is your experience before you apply any conscious strategies to manage it?" (e.g., "When you are not masking, how do you present?").
Example: The patient reported talking "too much" and interrupting "often" when unmasked.

Part 2: The Clinical Interview: Beyond the Checklist

Supplementary Symptom Exploration (Non-DSM but Highly Indicative)

These clusters of symptoms provide a richer clinical picture and help explain the patient's lived experience. This is where the "why" behind the symptoms is explored.

Symptom Cluster	Key Characteristics & Clinical Probes
1. Emotional Dysregulation	• Rejection Sensitive Dysphoria (RSD): Extreme emotional pain from perceived rejection, criticism, or failure. Emotional Intensity: Experiencing all emotions (sadness, anger, excitement) intensely, with little middle ground ("black and white" or all or nothing emotions). Metaphor: Neurotypical emotions are a pendulum swing; ADHD emotions go straight to the extremes. • Low Frustration Tolerance: Feeling overwhelmed by minor stressors others handle easily.
2. Executive Functioning Challenges	• Time Blindness: Chronic inability to accurately sense the passage of time or estimate how long tasks will take. Probe for specific examples of missed deadlines or last-minute rushes. • Task Initiation (Procrastination): Difficulty starting tasks, especially non-interesting ones. It's not laziness but an "initiation paralysis." • Working Memory Deficits ("Leaky Mental Bucket"): Forgetting why you entered a room, losing track of conversations, struggling to hold multi-step instructions. • Poor Planning/Prioritization: Difficulty breaking down projects and deciding what to do first. The brain sees "everything as equally important."
3. Motivation & Interest-Based Nervous System	• Performance is contingent on: The task being Novel, Interesting, Challenging, or Urgent (N.I.C.U.). • Action precedes motivation: They often must start a task (action) to then feel motivated to continue. Neurotypicals are often the opposite. • "Wall of Awful": A mental barrier of shame and frustration from past failures that makes starting similar tasks even harder.
4. Cognitive & Internal Experiences	Hyperfocus: Intense concentration on a stimulating or enjoyable task, leading to a loss of time and awareness of surroundings. (Overlaps with Autistic special interests). Constant Brain Chatter: A mind that is always active, with multiple streams of thought.. An ongoing stream of thoughts, often running, which is sought as a form of stimulation. Maladaptive Daydreaming: Getting lost in elaborate, detailed daydreams as a form of stimulation or escape (e.g., to fall asleep).
5. Social & Interpersonal	• Distractibility in Social Settings: Easily distracted by external stimuli (noise, movement) or internal thoughts (often triggered by something said). Conversational Challenges: Talking excessively, frequently interrupting (due to impulsivity), or zoning out if the conversation is boring or low-stimulation. Clinical Insight: The ADHD brain actively chases stimulation; a boring conversation prompts the mind to open "other tabs" of more stimulating thoughts.
6. Physical & Somatic Signs	Clumsiness and Poor Coordination: Higher incidence of bumping into things, dropping objects, or minor accidents due to lack of spatial awareness or distractibility. Sleeplessness/Insomnia: Difficulty falling asleep because the brain cannot turn off (constant brain chatter). Coping Mechanism: Focusing on a single, interesting topic (like a movie or special interest) can simulate a meditative state by concentrating the "mental tabs" onto one theme, reducing cognitive load, and allowing for relaxation/sleep.

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Part 4: Differential Diagnosis & Key Distinctions

The therapist provided a masterclass in differentiating overlapping conditions.

Condition	Overlap with ADHD	Key Distinguishing Factors (from transcript)
Autism Spectrum Disorder (ASD)	• Hyperfocus/Special Interests • Sensory Sensitivities • Emotional Dysregulation/RSD • Need for structure (in some)	• Focus/Inattention: In "pure" autism, the ability to focus is not intrinsically impaired. ADHD's core is variable, interest-driven attention. • "Out of Sight, Out of Mind": A hallmark of ADHD working memory deficits, not a core autistic trait. • Time Blindness: A core ADHD feature, not a diagnostic criterion for autism. • The "Why" of Distraction: In ADHD, the mind wanders seeking stimulation. In autism, distraction may be due to sensory overwhelm or a more focused internal monologue.
Anxiety Disorders	• Restlessness • Difficulty Concentrating	• The "Why" of Poor Concentration: In anxiety, the mind is distracted by ruminative, worry-based thoughts (usually theme-specific). In ADHD, the mind is distracted by any stimulating thought seeking novelty. • Motivation: Anxiety can cause avoidance due to fear. ADHD avoidance is due to a lack of intrinsic motivation and stimulation for the task itself.

Clinical Pearl from Transcript: "Diagnoses are clusters of symptoms that tell a better story... The 18 questions [ASRS] together tell me a story where it is more likely ADHD than anxiety or autism."

Part 5: Therapeutic Takeaways & Patient Education

Normalize and Validate: Frame symptoms as a neurotype, not a character flaw. Use phrases like "interest-based nervous system," not "lazy." Explain that their brain works differently, not brokenly.
Identify Coping Strategies: The patient already uses effective workarounds. Acknowledge and build on these (e.g., checklists for time blindness, body doubling for task initiation, media for sleep).
Provide a Coherent Narrative: Help the patient understand how their childhood and adult struggles connect to this diagnosis. The "homework" to connect past examples to the symptoms is crucial for self-understanding and acceptance.
Focus on Function, Not Just Diagnosis: The end goal is to help the patient develop self-compassion and implement strategies that improve their daily life.

BONUS) ADHD vs. Autism vs. Anxiety (fast differential cues)

Feature	ADHD	Autism	Anxiety disorders
Attentional pattern	Variable, interest-driven, distractible, time blindness; many “open tabs.”	Attention generally consistent unless sensory overload/special-interest focus; intense focus on circumscribed interests.	Attention narrowed to threat/specific worries; ruminative but theme-locked.
Social	Interrupts/talks excessively; misses cues when bored/distracted; masking common.	Core social-communication differences, need for predictability/routines; special-interest centric talk.	Social attentional shifts driven by fear/avoidance of evaluation or threat.
Motivation	Novelty/urgency required; action → motivation.	Predictability/structure preferred; interest-anchored engagement.	Motivation limited by worry/physiologic arousal; avoidance reduces anxiety.
Onset/course	Childhood onset; lifelong pattern; fluctuates with demands.	Early developmental history with social/behavioral markers.	Can be episodic; linked to stressors; not necessarily childhood-pervasive.
Sleep	Racing thoughts; trouble disengaging.	May resist transition if routine disrupted; sensory factors.	Insomnia from hyperarousal/worry, but content is threat-focused.

Sample Notes:

Client endorses longstanding, childhood-onset symptoms consistent with ADHD, Combined presentation: frequent task initiation delay, disorganization, forgetfulness of obligations, distractibility, time blindness, and sustained-attention deficits on non-preferred tasks; plus fidgeting, internal restlessness, feeling “driven by a motor,” excessive talking, interrupting, and difficulty waiting turn. Symptoms persist ≥6 months, present across school/work/home, and cause clinically significant impairment (missed/late deadlines, interpersonal friction, sleep-onset delay). ASRS screening positive (Part A above threshold; Part B elevated). Client employs masking strategies that reduce observable hyperactivity but not internal symptoms. Differential considerations include anxiety and autism; however, the interest-driven attentional variability, broad executive dysfunction, and pervasiveness across contexts are more consistent with ADHD. Rule-out medical/sleep contributors as indicated. Provisional diagnosis: ADHD, Combined presentation; proceed with multimodal treatment plan.