Name: DOB: / / MRN:

*Please return packet to PCBH when completed to be scored

Adult

ADHD
PACKET

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V10 – 1/19
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ADHD SCREENING PROCESS

OVERVIEW
1. Initial consultation with PCP or PCBH ” Almost everyone has some symptoms
2. Complete ADHD Packet similar to ADHD at some point in their
lives. If your difficulties are recent or
3. Follow-up consultation for detailed occurred only occasionally in the past, you
clinical interview* probably don't have ADHD. ADHD is
4. Discuss coping/treatment options diagnosed only when symptoms are severe
enough to cause ongoing problems in
* Additional evaluations may be recommended
more than one area of your life. These
persistent and disruptive symptoms can be
traced back to early childhood.”
SCREENERS
• PHQ-9 (Depression) & GAD-7 ( Anxiety) mayoclinic.org
• Cross-Cutting Symptom Measure
• BAARS-IV: ADHD Self-Report: Current
• Impairment Scale & Mood Monitor
• BAARS-IV: Other-Report: Childhood**
** Required i f no evid ence o f childhood impairment
provided ( e. g., assess ment, records, school reports)

NEXT STEPS
 1. Request supporting documentation . Get documentation from:
a. Previous providers who have conducted ADHD evaluations
b. School records that support ADHD childhood impairment
c. Informant who can support childhood impairment (optional)
 2. Schedule PCBH follow-up appointment in 2 -4
weeks. Bring supporting documentation.
 3. Complete this packet and return with provided envelope or to
your home clinic. Address to Primary Care Behavioral Health.
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DO I HAVE ADHD?

ATTENTION & CONCENTRATION DIFFICULTIES CAN BE CAUSED BY MANY

CONDITIONS INCLUDING: DEPRESSION, ANXIETY, LEARNING DIFFICULTIES,
SUBSTANCE ABUSE, TRAUMA, OR STRESS ( PERSONAL, WORK, ETC.)

THIS CAN MAKE ADHD A COMPLEX CONDITION TO UNDERSTAND &

DIAGNOSIS. A DETAILED ASSESSMENT AND GATHERING OF SUPPORTING
DOCUMENTATION IS AN IMPORTANT OF PROCESS. REVIEWING THIS TABLE
IS A GOOD FIRST STEP.

ADHD Other

Started in childhood Only as an adult

Life-long Situational

Significant impairment Impairment caused by stress,

caused by ADHD lack of skills, personality, etc.

Two settings or more Only one setting

Based on formal assessment Based on needs/wants

THERE ARE MANY WAYS OF TREATMENT AND COPING WITH ADHD. IN

ORDER TO BE CONSIDERED FOR MEDICATION TREATMENT, THE
FOLLOWING MUST BE TRUE:
 SYMPTOMS MEET CRITERIA FOR ADHD
 ABSENCE OF A SUSBTANCE ABUSE DISORDER
 ABSENCE OF A CONDITION THAT NEEDS TO BE TREATED FIRST
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COPING WITH
ATTENTION AND CONCENTRATION
DIFFICULTIES

1. Developing organizational skills

 Develop priorities (first things first)
 Time management (set a timer, realistic expectations)
 Create a system for tasks, bills, etc.

2. Understanding and adapting to learning style

 Reduce distractions (turn off technology, no multitasking)
 Write it down (to-do list, SMART goals)
 Actively manage procrastination (note fears, 10 minute rule)

3. Reducing stress and improving well-being

 Self-care: exercise and relaxation
 Get enough sleep (8 hours)
 Eat right (reduce caffeine, other substances)
 Set limits (pacing, learn to say no)

4. Taking next steps if needed

 Analyze the “problem” (vulnerabilities, triggers, strengths, etc.)
 Career counseling (interest, values, skills)
 Mental health therapy (cognitive-behavioral strategies)
 Practice mindfulness meditation

 Self-help
• Adult ADHD Tool Kit by Ramsay & Rostain
• Understand Your Brain, Get More Done by Ari Tuckman
• Taking Charge of Adult ADHD by Barkley
• Driven to Distraction by Hallowell & Ratey
• Mindfulness Prescription for ADHD by Lidia Zylowska
• Websites: Help4adhd.org, Helpguide.org

ADHD PACKET 

 Cross-Cutting Symptom Measure—Adult
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Name: _______________________________

Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best
describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

None Slight Mild Moderate Severe

During the past TWO (2) WEEKS, how much (or how often) have you Rare, less
More than Nearly
Not at than a Several
been bothered by the following problems? half the every
all day days
days day
or two
II. 1. Feeling more irritated, grouchy, or angry than usual? 0 1 2 3 4

III. 2. Sleeping less than usual, but still have a lot of energy? 0 1 2 3 4
0 1 2 3 4
3. Starting lots more projects than usual or doing more risky things than
usual?
V. 4. Unexplained aches and pains (e.g., head, back, joints, abdomen,
legs)? 0 1 2 3 4
5. Feeling that your illnesses are not being taken seriously enough? 0 1 2 3 4
VII. 0 1 2 3 4
6. Hearing things other people couldn’t  hear,  such  as  voices  even  when
no one was around?
7. Feeling that someone could hear your thoughts, or that you could
hear what another person was thinking? 0 1 2 3 4
VIII. 8. Problems with sleep that affected your sleep quality over all? 0 1 2 3 4
IX. 9. Problems with memory (e.g., learning new information) or with
location (e.g., finding your way home)? 0 1 2 3 4
X. 10. Unpleasant thoughts, urges, or images that repeatedly enter your
mind? 0 1 2 3 4
11. Feeling driven to perform certain behaviors or mental acts over and
over again? 0 1 2 3 4
XI. 12. Feeling detached or distant from yourself, your body, your physical
surroundings, or your memories? 0 1 2 3 4
XII. 13. Not knowing who you really are or what you want out of life? 0 1 2 3 4
14. Not feeling close to other people or enjoying your relationships
with them? 0 1 2 3 4
XIII. 15. Drinking at least 4 drinks of any kind of alcohol in a single day? 0 1 2 3 4
16. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing
tobacco? 0 1 2 3 4
17. Using any of the following medicines ON YOUR OWN, that is, 0 1 2 3 4
without  a  doctor’s  prescription,  in  greater  amounts  or  longer  than  
prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or
Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or
drugs like marijuana, cocaine or crack, club drugs (like ecstasy),
hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or
methamphetamine (like speed)]?

Adapted from "DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult" (I, IV, and VI removed)
For original go to http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures
Copyright © 2013 American Psychiatric Association. All Rights Reserved.
This material can be reproduced without permission by researchers and by clinicians for use with their patients.
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NOTES & QUESTIONS