The First Adult ADHD Consult Is Here to Stay

Adult ADHD presentations have increased sharply in general practice. Patients arrive with genuine distress, strong expectations, and often a backlog of information (and misinformation). Meanwhile, the pathway can be slow, the comorbidity load is high, and the risk profile requires careful, consistent assessment.

This is exactly the type of consult where a simulation can make your real-world performance feel calmer, faster, and more defensible.

In this week’s MediSims case, you meet Tilly Carter, a 20-year-old university student, presenting for an initial ADHD assessment. She wants two things:

1. to know whether ADHD is a plausible explanation, and
2. to understand what “management” actually looks like—especially while waiting for specialist assessment.

What This Consult Is Really Testing

Most clinicians already know the symptom list. The difficulty is executing a tight, defensible sequence in a short consult.

The simulation is designed to train these competencies:

1) Clarify symptoms and impairment (not just “inattention”)

High-yield lines of enquiry include:

• What exactly is hard: starting tasks, sustaining focus, finishing tasks, prioritising, time blindness, forgetting, losing items
• Where it shows up: uni, work, home, relationships, driving, finances
• Concrete examples and frequency
• “What’s the cost?” (missed deadlines, academic warning, job performance, conflict, burnout)

2) Establish developmental timeline

A credible ADHD assessment requires developmental anchoring. In the sim, Sophie can provide:

• Childhood patterns: “bright but not applying herself,” forgotten homework, messy bag/desk
• Teacher comments like “distracted,” “inconsistent,” “needs organisation”
• No formal diagnosis

3) Screen for differential diagnoses and comorbidities

Adult ADHD rarely arrives alone, and several conditions can mimic it.

A safe first consult screens for:

• Anxiety and depression (and whether symptoms are primary vs secondary)
• Sleep disorders and circadian dysregulation
• Trauma/stress, burnout
• Substance use (including non-prescribed stimulant exposure)
• Bipolar-spectrum red flags (episodic decreased need for sleep, elevated mood, increased goal-directed activity, risky behaviour)
• Medication contributors and basic medical causes where relevant (e.g., thyroid dysfunction, iron deficiency)

In Sophie’s case, she reports significant stress and poor sleep around exams and uses caffeine heavily. She denies manic symptoms. If asked carefully, she discloses trying a friend’s ADHD medication once—useful for risk framing and patient education.

4) Risk and safety-netting (do not skip)

Even if you’re time-poor, your documentation should show you considered:

• Self-harm and suicidality
• Substance misuse pattern and dependence risk
• Driving and occupational safety where relevant
• Cardiovascular risk history if medication is likely to be discussed later (and local prescribing pathways require it)

5) Set expectations: assessment pathway and what you can do now

Patients often believe there is a single test or scan. The simulation trains you to explain, in plain language, that assessment usually involves:

• A structured clinical history
• Evidence of childhood onset and cross-setting impairment
• Standardised questionnaires (as adjuncts, not standalone diagnostics)
• Collateral information where feasible (family, school reports)

Then you pivot to management that starts today—because the waiting period is often the hardest part.

Common Pitfalls This Simulation Helps You Avoid

1. “Symptom checklist only” without functional impairment or developmental timeline
2. Missing bipolar red flags (the high-stakes miss)
3. Ignoring sleep and anxiety and then treating “ADHD-like” symptoms in isolation
4. Not asking about substance use or non-prescribed stimulants
5. Overpromising medication or presenting it as the only solution
6. Vague follow-up (“we’ll see”) rather than a staged plan with next steps

Why This Case Works as a Training Tool

TIlly isn’t a caricature. She’s anxious but functional, high-achieving but slipping, and worried she’s “just lazy.” That mix forces the clinician to do what real practice requires: combine empathy with structure, and reassurance with boundaries.

If you can run this consult smoothly in simulation, you’ll be faster, more confident, and more consistent when the real patient sits down.

Try the Simulation

Run the case as many times as you need. Practise phrasing, structure, and time control. Then take the same template into your next real ADHD consult.

Disclaimer: This is educational content for clinicians and learners. It is not personal medical advice.

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