ADHD

[Shikima]

Currently and anecdotal, we're seeing an increase in requests, primarily from college age students who give the 'ole - "I took my friends Adderall and I can study better."

It's getting pretty bad with the PCPs, whom we partner with, have started saying no outright and are sending over to the clinic for further evaluation. Those who are currently on stimulants by the PCPs are being effectively cut off and sent to the clinic for further evaluation.

In a nutshell, is there a good collection of screening tools which has good validity in helping to screen those out for psycho-stimulants? Perhaps something of an easy decision making tree rather than citing the obvious which PCPs can use to help them through the process?

I'm hoping to ease the burden and requirements but also lessening demand through bogus claims.

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[F0nzie]

I don't think there are any shortcuts here man. You still need a standard psychiatric evaluation examining symptoms, ruling out other medical or psychiatric causes for inattention, childhood hx, collateral info, ASRS screening tool, drug testing, referring out for neuropsych testing and TOVA, monitoring state pharmacy for abuse or diversion, etc... In the end it's a clinical diagnosis and you need to trust that the patient is not taking it as a performance enhancer or to get high.

 

[erg923]

Currently and anecdotal, we're seeing an increase in requests, primarily from college age students who give the 'ole - "I took my friends Adderall and I can study better."

It's getting pretty bad with the PCPs, whom we partner with, have started saying no outright and are sending over to the clinic for further evaluation. Those who are currently on stimulants by the PCPs are being effectively cut off and sent to the clinic for further evaluation.

In a nutshell, is there a good collection of screening tools which has good validity in helping to screen those out for psycho-stimulants? Perhaps something of an easy decision making tree rather than citing the obvious which PCPs can use to help them through the process?

I'm hoping to ease the burden and requirements but also lessening demand through bogus claims.

The Wender-Utah is probably your best first line screening tool/instrument for adults claiming ADHD. Pay attention to how to score the thing. 10 minutes. Sensitivity and specificity are alright, better and less face valid than the connors scales.

 

[Shikima]

The Wender-Utah is probably your best first line screening tool for adults claiming ADHD. Pay attention to how to score the thing.

Can you provide more insight in how to use it effectively within the context for collaboration both with PCPs and therapists? Can this be applied to all age groups as I thought this was for children only.

 

[erg923]

Can you provide more insight in how to use it effectively within the context for collaboration both with PCPs and therapists? Can this be applied to all age groups as I thought this was for children only.

No. Wender Utah are retrospective questions...for adults claiming AD/HD. I would use this first, then only proceed with focused clinical interviewing and history (which takes a good deal of time) if you are near the cutoff score. I would do this yourself, but make known the rationale for this to your PCPs and therapists.

 

[Shikima]

Thanks, I appreciate it!

Edit: You too Fonz!

 

[erg923]

There are many ways to skin a cat, but this is what I do in my PCP clinic. Endorsed/blessed by our facility neuropsychologists and seems to be efficient and minimizes time spent on cases that are just ridiculous on the face of it...but you need to stats to back you up so peeps don't get all exicted.

 

[PistolPete]

What do you guys do if you suspect a 6 year old patient's mother may be diverting a stimulant, other than checking the state prescription drug database?

 

[shan564]

I haven't run into this situation myself, but I wonder if we were to try suggesting conservative management first-line (occupational therapy, behavioral modification, sleep hygiene), that might screen out some of the people who don't really want to improve...

 

[Shikima]

I haven't run into this situation myself, but I wonder if we were to try suggesting conservative management first-line (occupational therapy, behavioral modification, sleep hygiene), that might screen out some of the people who don't really want to improve...

I'm doing that now, got a complaint and was called a jerk.

 

[shan564]

I'm doing that now, got a complaint and was called a jerk.

Malingerers will be manipulative. Hopefully the person who is fielding these "complaints" will recognize what a drug-seeker is.

 

[st2205]

I haven't run into this situation myself, but I wonder if we were to try suggesting conservative management first-line (occupational therapy, behavioral modification, sleep hygiene), that might screen out some of the people who don't really want to improve...

That would screen out just about everybody. Then again, the people who should be screened out would approximate "just about everybody."

I do tire of these evals. Honestly, my attention problems are worse than these people. I wish I could take a stimulant. We typically send them for psychological testing first, which wastes an appointment with us (we've got a large waiting list). So PCP sends to us, patient waits 4 months, then we see them and say get testing. Then that's another 3 months. Anyway, the testing thing is kind of non-sense and we're using it as a way to filter and essentially pass the buck. Also, then people come back from testing and, though them not really being clinically appropriate, now you've got someone with this, in essence, certificate that's good indefinitely for adderall refills. Obviously you're not obliged to anything, but i find it disingenuous to send people for testing, take up 2-3 days with them, have them drop $400, and then you say "well, despite your testing, you're not a good candidate."

Anyway, posting this before going to bed. I've left out a lot that I'm sure someone will jump on and be appalled by, but I'll be content with clarifying that later.

 

[Doctor Bagel]

That would screen out just about everybody. Then again, the people who should be screened out would approximate "just about everybody."

I do tire of these evals. Honestly, my attention problems are worse than these people. I wish I could take a stimulant. We typically send them for psychological testing first, which wastes an appointment with us (we've got a large waiting list). So PCP sends to us, patient waits 4 months, then we see them and say get testing. Then that's another 3 months. Anyway, the testing thing is kind of non-sense and we're using it as a way to filter and essentially pass the buck. Also, then people come back from testing and, though them not really being clinically appropriate, now you've got someone with this, in essence, certificate that's good indefinitely for adderall refills. Obviously you're not obliged to anything, but i find it disingenuous to send people for testing, take up 2-3 days with them, have them drop $400, and then you say "well, despite your testing, you're not a good candidate."

Anyway, posting this before going to bed. I've left out a lot that I'm sure someone will jump on and be appalled by, but I'll be content with clarifying that later.

The general perception I've heard in my community is that neuropsych testing seems to always come back positive for ADHD or ADHD like symptoms, and then you're even more stuck prescribing stimulants after the patient wasted a ton of time and money.

 

[birchswing]

The general perception I've heard in my community is that neuropsych testing seems to always come back positive for ADHD or ADHD like symptoms, and then you're even more stuck prescribing stimulants after the patient wasted a ton of time and money.

Always makes it seem like a bad test, but higher than expected (or than you'd like) might be normal given the sample being tested (presumably people being tested for ADHD have ADHD at a higher rate than the entire population even if there are people in that sample who want a diagnosis only for getting simulants)?

 

[nitemagi]

I'd like some psychometrics that catch a ceiling/floor effect for overreporters.

 

[shan564]

That would screen out just about everybody. Then again, the people who should be screened out would approximate "just about everybody."

Yeah, that's the point. I wouldn't do that for a person who obviously has moderate to severe ADHD, but when it's iffy, I'd at least gauge their interest in trying conservative treatments, and then maybe offer something less abusable like Strattera.

 

[Shikima]

Malingerers will be manipulative. Hopefully the person who is fielding these "complaints" will recognize what a drug-seeker is.

Have a pretty good office manager. The other thing which saves me much headache is that I document as much as I can in quotes and probe for intent.

 

[Shikima]

The general perception I've heard in my community is that neuropsych testing seems to always come back positive for ADHD or ADHD like symptoms, and then you're even more stuck prescribing stimulants after the patient wasted a ton of time and money.

I've noticed this problem too, which drives my concern further.

I was reflecting further last night, and we often dismiss the rule, not explained by another disorder.

 

[erg923]

The general perception I've heard in my community is that neuropsych testing seems to always come back positive for ADHD or ADHD like symptoms, and then you're even more stuck prescribing stimulants after the patient wasted a ton of time and money.

I'm not sure wat this means really, as there is no neuropsychological profile that is diagnostic or "rules in" AD/HD, nor is there one that rules it out.

Attention tests are very important for discovering what a person can and cannot do, not for what diagnosis they do or do not have. The DSM has absoltely no criteria for "manifests actually attention deficits" as part of its diagnostic criteria for ADHD, right? And while it is true that people with ADHD are a bit more likely to have certain cognitive profiles than are people without ADHD, most people with ADHD do not have this particular profile and most people with this profile do not have ADHD. Psychological/neuropsychologcial testing has limited utility here unles there is a diffiential on the table that necessitates testing, such as a learning disorder, autism, etc. Although it is possible for researchers to learn quite a bit about ADHD from small-to-modest mean differences in test performance, attention tests do not improve individual diagnostic accuracy.

 

[Doctor Bagel]

I'm not sure wat this means really, as there is no neuropsychological profile that is diagnostic or "rules in" AD/HD, not is there one that rules it out.

Attention tests are very important for discovering what a person can and cannot do, not for what diagnosis they do or do not have. The DSM has absoltely no criteria for "manifests actually attention deficits" as part of its diagnostic criteria for ADHD, right? And while it is true that people with ADHD are a bit more likely to have certain cognitive profiles than are people without ADHD, most people with ADHD do not have this particular profile and most people with this profile do not have ADHD. Psychological/neuropsychologcial testing has limited utility here unles there is a diffiential on the table that necessitates testing, such as a learning disorder, autism, etc. Although it is possible for researchers to learn quite a bit about ADHD from small-to-modest mean differences in test performance, attention tests do not improve individual diagnostic accuracy.

So maybe we don't have the time (or at least take the time) to read the reports in enough detail to appreciate them.

 

[AcronymAllergy]

Like erg mentioned, from a neuropsych side, there isn't a particular cognitive profile I look for to rule in/out a diagnosis of ADHD; that's primarily what self-report and interview are meant to do. The cognitive data can certainly support a diagnosis and help with recommendations, and perhaps provide additional information in a more borderline case, but it's not diagnostic in and of itself.

Part of the problem is of course that the symptoms of ADHD are so common and non-specific that, if read them, the majority of the population will endorse them to a near-clinical degree. This is one of the reasons I'll use a variety of self-report measures in my evals, with included negative impression management scales, in addition to focusing not just on symptoms, but on the actual degree of past and current resulting impairment. I also try to obtain school records and collateral report when possible, although this is unfortunately rarely available.

I also always focus on behaviorally-based recommendations in my reports and feedback sessions with patients.

And yes, the referrals spike right before the start of fall semester, and again in early winter and late spring as finals roll around.

 

[Shikima]

Like erg mentioned, from a neuropsych side, there isn't a particular cognitive profile I look for to rule in/out a diagnosis of ADHD; that's primarily what self-report and interview are meant to do. The cognitive data can certainly support a diagnosis and help with recommendations, and perhaps provide additional information in a more borderline case, but it's not diagnostic in and of itself.

Part of the problem is of course that the symptoms of ADHD are so common and non-specific that, if read them, the majority of the population will endorse them to a near-clinical degree. This is one of the reasons I'll use a variety of self-report measures in my evals, with included negative impression management scales, in addition to focusing not just on symptoms, but on the actual degree of past and current resulting impairment. I also try to obtain school records and collateral report when possible, although this is unfortunately rarely available.

I also always focus on behaviorally-based recommendations in my reports and feedback sessions with patients.

And yes, the referrals spike right before the start of fall semester, and again in early winter and late spring as finals roll around.

I read it [online/pamplete] and I have it! It says I need a stimulant!

 

[AcronymAllergy]

I read it [online/pamplete] and I have it! It says I need a stimulant!

...it'd be funnier if it weren't so true.

Edit: In general, I think neuropsych has the potential to be more helpful than it currently is, perhaps once we do a better job of delineating the potential subtypes of ADHD (e.g., sluggish cognitive tempo variant) and developing more sensitive and potentially ecologically-congruent measures.

But as things currently stand, the way I see it, one of our biggest advantages is simply that we have the ability to spend 3-4 hours with a person (and another 3-4 hours reviewing records, evaluating results, and attempting to contact collaterals) rather than 30-60 minutes. Many of the qualitative observations I make during that time will then feed into my recommendations.

 

[Shikima]

Didn't you know, everyone is Bipolar and has ADHD! Benzos and Adderall for all.....

I'll skip the middle man and put a fishbowl with loose pills in it. Grab a handful on the way out. That'll likely be the correct dosage for you.

 

[AcronymAllergy]

And don't forget the opiates. Never forget the opiates.

 

[WingedOx]

Didn't you know, everyone is Bipolar and has ADHD! Benzos and Adderall for all.....

I'll skip the middle man and put a fishbowl with loose pills in it. Grab a handful on the way out. That'll likely be the correct dosage for you.

You didn't realize? An upper and a downer create a perfect equilibrium! Pretty sure that's on the boards

In the grad scheme of things, the rate limiting step in my assessment is usually more reliant on the question of "how likely is this patient to cause a problem for himself or myself should I prescribe a stimulant?" than about the severity of the symptoms themselves given what you've all posted above.

if someone comes in like the OP's situation where they are admitting to taking a non-prescribed controlled substance, they're going to have quite a few hurdles placed in front of them to demonstrate adherence to treatment before they have any chance of walking out with a stimulant.

 

[AcronymAllergy]

You didn't realize? An upper and a downer create a perfect equilibrium! Pretty sure that's on the boards

In the grad scheme of things, the rate limiting step in my assessment is usually more reliant on the question of "how likely is this patient to cause a problem for himself or myself should I prescribe a stimulant?" than about the severity of the symptoms themselves given what you've all posted above.

if someone comes in like the OP's situation where they are admitting to taking a non-prescribed controlled substance, they're going to have quite a few hurdles placed in front of them to demonstrate adherence to treatment before they have any chance of walking out with a stimulant.

Which is of course compounded by the increased rates of/risk for substance misuse in individuals with ADHD in general. So if the person has already demonstrated a h/o such misuse, they probably aren't doing themselves any favors.

 

[WingedOx]

Which is of course compounded by the increased rates of/risk for substance misuse in individuals with ADHD in general. So if the person has already demonstrated a h/o such misuse, they probably aren't doing themselves any favors.

Bingo.

 

[Shikima]

Then there is the added concern, those who do have true ADHD and have a history of addictions which partially is meant to self-medicate for the symptoms, creates a larger conundrum.

 

[Shikima]

I feel there needs to be a disclaimer how electrolytes are good for people, so it must be good for plants too.

 

[WingedOx]

Then there is the added concern, those who do have true ADHD and have a history of addictions which partially is meant to self-medicate for the symptoms, creates a larger conundrum.

Risk v Benefit. The most exciting inter-conference matchup of the week.

 

[smalltownpsych]

I personally hate ADHD assessment referrals. Almost nobody wants to hear that it is not ADHD or to try other alternatives before medication. Also, we don't have good diagnostic tests for it and there are so many unknowns about the disorder/syndrome. I think we need way more research in this area and especially long term. I actually see ADHD as more of a symptom (like many of our "disorders") that can point to a variety of underlying issues including attachment, trauma, learning disorders, bad parenting, executive functioning deficits (which can also have multiple etiologies), anxiety disorders, and social difficulties or deficits.

 

[Shikima]

I personally hate ADHD assessment referrals. Almost nobody wants to hear that it is not ADHD or to try other alternatives before medication. Also, we don't have good diagnostic tests for it and there are so many unknowns about the disorder/syndrome. I think we need way more research in this area and especially long term. I actually see ADHD as more of a symptom (like many of our "disorders") that can point to a variety of underlying issues including attachment, trauma, learning disorders, bad parenting, executive functioning deficits (which can also have multiple etiologies), anxiety disorders, and social difficulties or deficits.

...and sleep deprivation.

 

[nitemagi]

I personally hate ADHD assessment referrals. Almost nobody wants to hear that it is not ADHD or to try other alternatives before medication. Also, we don't have good diagnostic tests for it and there are so many unknowns about the disorder/syndrome. I think we need way more research in this area and especially long term. I actually see ADHD as more of a symptom (like many of our "disorders") that can point to a variety of underlying issues including attachment, trauma, learning disorders, bad parenting, executive functioning deficits (which can also have multiple etiologies), anxiety disorders, and social difficulties or deficits.

That's what I tell patients -- Attention is a heterogeneous problem. It has many causes, including sleep deprivation, environment, emotional, workflow, anxiety (I think some distractibility is actually micro-anxiety moments with quick avoidance). I push for all my patients to do a round of therapy (CBT plus other interventions) prior to meds, if possible.

 

[Shikima]

That's what I tell patients -- Attention is a heterogeneous problem. It has many causes, including sleep deprivation, environment, emotional, workflow, anxiety (I think some distractibility is actually micro-anxiety moments with quick avoidance). I push for all my patients to do a round of therapy (CBT plus other interventions) prior to meds, if possible.

I think this is a very good approach to adopt.

 

[WingedOx]

...and sleep deprivation.

yup.

That's what I tell patients -- Attention is a heterogeneous problem. It has many causes, including sleep deprivation, environment, emotional, workflow, anxiety (I think some distractibility is actually micro-anxiety moments with quick avoidance). I push for all my patients to do a round of therapy (CBT plus other interventions) prior to meds, if possible.

I could have left work a half hour ago if I'd have gone to bed last night instead of watching the Broncos game. Instead I have about 12 tabs open and 2 eval notes left.

 

[AcronymAllergy]

Attention problems are pretty ubiquitous, yep; although the syndrome of ADHD itself is a bit more well-defined than just that, fortunately (outside of just DSM symptoms)...

...unfortunately, it's tough to parcel out the syndrome vs. attention/concentration difficulties due to X (with "X" being everything just listed above). My take is to always try to treat the "X" first, and if the attention problems are still around, then maybe it's ADHD. That almost never goes over well, though.

Or, theoretically, I try to establish if the attention problems predated "X." Which, again, is often an exercise in futility. But if I'm able to actually get in touch with a parent, and can combine that with a relatively thorough clinical history and some testing data, I feel like that often helps me ferret out at least a few of the ADHD impostor syndromes.

 

[Ceke2002]

I had my case presented (without identifying details) as part of a national psychiatry convention back in the 90s. Apparently I was the example of the classic presentation versus other types of presentation of ADHD (or childhood ADHD, adult ADD in my case). Damn I wish I could find a copy of the lecture notes, or any of the writings that were done from that convention. Might be some interesting reading.

 

[smalltownpsych]

I have seen a few pure ADHD people where it appears something neurological is going on and the medication is clearly beneficial. Unfortunately these seem to be the exception rather than the rule. I wish I could refer these cases to a neuropsychologist because they tend to be more thorough and have a much higher level of expertise in diagnosis and assesements than a general practitioner of psychology such as myself has. We don't have one within a four hour drive though and they tend to be more expensive anyway. Most people involved just want me to confirm that it is ADHD so that they can give them a stimulant and move on.

Every day we fight against people's natural dynamics and the pressures to just "go with the flow". It gets a bit tiring at times. Some of that is coming because a patient of mine with Borderline PD was sent to a short term psychiatric unit to cure them because 6 months into my DBT informed treatment that was actually going well, it wasn't working fast enough for the family.

 

[Ceke2002]

I have seen a few pure ADHD people where it appears something neurological is going on and the medication is clearly beneficial. Unfortunately these seem to be the exception rather than the rule.

Yeah it's kinda weird when you actually have ADD/ADHD and you take stimulants, because unless you're doing something hardcore like crystal meth, or taking high enough doses of other types of amphetamines to actually get off your face, it doesn't really 'speed' you up but at the same time it doesn't really slow you down either (not in my experience at least). For me it was more like when the medication (Dextroamphetamine) kicked in it was if my brain was being tuned into the correct signal for once, and that in turn made me feel more mentally relaxed, but at the same time I'd still get all the jittery, restless, insomnia type physical sensations on top of that. Just personally I found being on medication was fine for about the first 2 weeks, kind of like my brain was finally getting a chance to breathe a sigh of relief and bask in normality, but after that I was kind of way over the side effects and I just started feeling really grungy, so the cost/benefit analysis of medication wasn't really in favour of me staying on it in the end.

 

[Shikima]

I love how you're a "jerk" for not giving them what they want, not what they need.

 

[Ceke2002]

I love how you're a "jerk" for not giving them what they want, not what they need.

I must admit I don't really get the 'drive' of some people to try and scam stimulant meds off Doctors. Maybe taking them is different when you don't have the conditions they're actually used for, but I certainly wouldn't place stimulant based medications like Ritalin or Dexamphetamine very high on my list of 'drugs I (used to) like to party on'. And besides why go through all the hassle of bothering a Doctor when it's far easier to just score illicit amphetamines on the street? Like just get a dealer already FFS!

 

[AcronymAllergy]

I must admit I don't really get the 'drive' of some people to try and scam stimulant meds off Doctors. Maybe taking them is different when you don't have the conditions they're actually used for, but I certainly wouldn't place stimulant based medications like Ritalin or Dexamphetamine very high on my list of 'drugs I (used to) like to party on'. And besides why go through all the hassle of bothering a Doctor when it's far easier to just score illicit amphetamines on the street? Like just get a dealer already FFS!

This is one of the reasons folks seek an ADHD diagnosis and subsequent psychostimulant prescription (i.e., diversion).

 

[Ceke2002]

This is one of the reasons folks seek an ADHD diagnosis and subsequent psychostimulant prescription (i.e., diversion).

Ah, of course. Geez I've been out of the game for so long I plum forgot about that aspect (which is actually a good thing).

 

[sloop]

Then there is the added concern, those who do have true ADHD and have a history of addictions which partially is meant to self-medicate for the symptoms, creates a larger conundrum.

I think I was taught in one of our second year lectures about ADD pharmacotherapy that, in general, medicated ADD patients have lower rates of drug addiction and minor legal offenses than untreated peers. Is this wrong? Is there good reason to believe that patients who appear to have a substance use disorder that is explainable as self-medication would be worse off on psychostimulants? Just curious.

FWIW, we were also taught that the response rate for psychotherapy alone was "dismal" compared to pharmacotherapy or pharmacotherapy + psychotherapy. Is that also inaccurate? I only ask because I see a lot of psychiatrists in this thread recommending a trial of therapy before starting stimulants.

 

[smalltownpsych]

I think I was taught in one of our second year lectures about ADD pharmacotherapy that, in general, medicated ADD patients have lower rates of drug addiction and minor legal offenses than untreated peers. Is this wrong? Is there good reason to believe that patients who appear to have a substance use disorder that is explainable as self-medication would be worse off on psychostimulants? Just curious.

FWIW, we were also taught that the response rate for psychotherapy alone was "dismal" compared to pharmacotherapy or pharmacotherapy + psychotherapy. Is that also inaccurate? I only ask because I see a lot of psychiatrists in this thread recommending a trial of therapy before starting stimulants.

Psychotherapy is not very effective for ADHD according to the research but most of the ADHD referrals have other issues that are causing the symptoms. I have been part of intensive environmental interventions that paid off incredibly well for patients with ADHD. It is hard to change the environment though. As far as medication for ADHD preventing later substance abuse, have never seen that research. Drug addicts don't do very well on medications with abuse potential based on my own observations, but there always seem to be researchers motivated to conduct studies that find some beneficial effects. Unfortunately, I usually see major flaws in these types of studies, but they still seem to get more play.

 

[PikminOC]

I'm doing that now, got a complaint and was called a jerk.

Why didn't you give them what they want?

 

[PikminOC]

Shikma, ask these kids for a uds. They wont do it.

 

[splik]

I think I was taught in one of our second year lectures about ADD pharmacotherapy that, in general, medicated ADD patients have lower rates of drug addiction and minor legal offenses than untreated peers. Is this wrong?

yes this is wrong. the evidence is equivocal at best. patients with ADHD are more likely to have substance use problems, legal troubles, and die in accidents but there is no good evidence that treating ADHD makes any difference to these outcomes (data is mixed at best) though the ADHD moral entrepreneurs use the poorer outcomes to demand more access to treatment.

 

[shan564]

yes this is wrong. the evidence is equivocal at best. patients with ADHD are more likely to have substance use problems, legal troubles, and die in accidents but there is no good evidence that treating ADHD makes any difference to these outcomes (data is mixed at best) though the ADHD moral entrepreneurs use the poorer outcomes to demand more access to treatment.

If anything, I think that the data at least tell us that giving a stimulant to a kid with ADHD probably doesn't increase their risk of substance abuse, as is often a concern when prescribing a schedule II controlled substance. Of course, that is predicated on the assumption that the kid actually has ADHD.