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A 38-year-old female executive presents for evaluation of concentration difficulties that have worsened since her recent promotion to a senior management role. She describes difficulty prioritizing competing tasks, frequently starting projects but not completing them, chronic lateness despite multiple alarm systems, and an inability to maintain organizational systems at work. Her childhood school records describe her as 'bright but daydreamy' with inconsistent academic performance. She has no history of substance use, mood disorders, or anxiety, and her PHQ-9 score is 3. Neuropsychological testing reveals average IQ but significant deficits on the Wisconsin Card Sorting Test and Trail Making Test Part B. Which assessment interpretation best accounts for this clinical presentation?
Explanation
Adult ADHD, particularly the predominantly inattentive presentation in women, is frequently undiagnosed until increased life demands exceed compensatory mechanisms. Executive function deficits on neuropsychological testing — particularly on measures of cognitive flexibility, set-shifting, and alternating attention — combined with a childhood history of inattentive symptoms, support the diagnosis. High intellectual ability can mask ADHD symptoms for decades until environmental demands outpace executive capacity.
Key Takeaway
High-functioning adults with predominantly inattentive ADHD often decompensate when career advancement increases executive demands beyond their compensatory capacity, and childhood history of inattention with inconsistent performance is critical evidence for the diagnosis.