Adults who do NOT have ADHD

[meow1985]

Oh, for goodness sakes! Of course many of us think (and say) this. Stop being so coy. No shame here, son.

It is actually very, very reasonable to assume this/these fact vs the other. In fact, many, many people are indeed lazy. Only some of those lazy people will have an actual psychiatric disorder. If we have to rely on a cognitive heuristic ….. I would bet on "lazy" vs "psychiatrically disordered" anytime.

Further, is it statistically probable that 30% of your peds Medicaid population have the same (neurodevelopment) psychiatric disorder that is about estimated to be about 3-5% of the general population per extensive DSM survey research? If you believe that? Or maybe ****ty parents = ****ty behaving kids? I mean, come on folks?

Thank you. A part of me still thinks that a lazy, undisciplined is quite likely to answer affirmatively to some of the ADHD questions. Like, reluctance to start tasks that require sustained mental effort, anyone?

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[Mass Effect]

Thank you. A part of me still thinks that a lazy, undisciplined is quite likely to answer affirmatively to some of the ADHD questions. Like, reluctance to start tasks that require sustained mental effort, anyone?

You really should get out of this type of thinking or make a blanket rule that you just don't treat ADHD. Your thinking is just plain unfair to patients.

 

[Old&InTheWay]

You really should get out of this type of thinking or make a blanket rule that you just don't treat ADHD. Your thinking is just plain unfair to patients.

I agree, and I find as time goes on, I have tended to see traits such as "laziness" or "lack of discipline" as symptoms of internal struggle, rather than personal, moral, or characterological failings. I think regardless of whether seeing things this way is it objectively true, it is a more useful and helpful schema if the goal is to help people.

 

[meow1985]

You really should get out of this type of thinking or make a blanket rule that you just don't treat ADHD. Your thinking is just plain unfair to patients.

I said a part of me thinks this way. I am actively working on it, labeling it and bracketing it as countertransference. I was naming what’s going on, that’s part of the change process.

 

[Mass Effect]

I said a part of me thinks this way. I am actively working on it, labeling it and bracketing it as countertransference. I was naming what’s going on, that’s part of the change process.

Yes and I'm glad it's changing. I just would have expected it to have changed before graduating residency, which is why I said what I did.

 

[psychacad]

I said a part of me thinks this way. I am actively working on it, labeling it and bracketing it as countertransference. I was naming what’s going on, that’s part of the change process.

We all have our blind spots. Better be aware of problematic patterns than shaming people.

 

[splik]

You really should get out of this type of thinking or make a blanket rule that you just don't treat ADHD. Your thinking is just plain unfair to patients.

I’m not sure I agree. I don’t typically treat ADHD. My pts will see a different psychiatrist for that. there are lots of psychiatrists in private practice who dont treat serious mental illness or patients with personality disorders or addiction or any number of disorders. As long as you aren’t doing a disservice to patients by preventing them from receiving care I believe we should have the autonomy to focus on what we want or where are strengths lie.

 

[meow1985]

Yes and I'm glad it's changing. I just would have expected it to have changed before graduating residency, which is why I said what I did.

Interestingly, in residency my longitudinal clinic had a relatively high functioning population, and for a while it was all ADHD intakes all the time. So I may have gotten jaded, and it may have actually increased countertransference. Also in residency no one took issue with not prescribing stimulants, quite the opposite. This is good feedback for those involved in my residency training, if I ever get a chance to give it.

 

[Mass Effect]

I’m not sure I agree. I don’t typically treat ADHD. My pts will see a different psychiatrist for that. there are lots of psychiatrists in private practice who dont treat serious mental illness or patients with personality disorders or addiction or any number of disorders. As long as you aren’t doing a disservice to patients by preventing them from receiving care I believe we should have the autonomy to focus on what we want or where are strengths lie.

That's exactly what I said? I told the poster to just not treat ADHD at all if he is still in the mindset that ADHD folks are lazy.

 

[hamstergang]

That's exactly what I said? I told the poster to just not treat ADHD at all if he is still in the mindset that ADHD folks are lazy.

That poster didn't say that patients with ADHD are lazy, but rather that lazy people would check off some of the ADHD boxes ("a lazy, undisciplined is quite likely to answer affirmatively to some of the ADHD questions"). This fact is part of the challenge of giving out the diagnosis appropriately.

 

[Mass Effect]

That poster didn't say that patients with ADHD are lazy, but rather that lazy people would check off some of the ADHD boxes ("a lazy, undisciplined is quite likely to answer affirmatively to some of the ADHD questions"). This fact is part of the challenge of giving out the diagnosis appropriately.

Please read all the posts in order to put the conversation in context. That particular poster said not 5 posts before the one you're quoting:

"Though I was aware it's a neurodevelopmental disorder, ADHD still occupied the same space in my mind as "poor parenting/chaos at home/bad kid syndrome," "undisciplined" and "lazy."

Then that poster thanked another poster who said:

"In fact, many, many people are indeed lazy. Only some of those lazy people will have an actual psychiatric disorder. If we have to rely on a cognitive heuristic ….. I would bet on "lazy" vs "psychiatrically disordered" anytime."

My comment in response to the poster appearing to agree with the poster who said they would bet on lazy over psychiatrically disordered was "You really should get out of this type of thinking or make a blanket rule that you just don't treat ADHD. Your thinking is just plain unfair to patients" because the poster clearly has a bias against ADHD and that bias is not fair to patients.

My comment after that was "I told the poster to just not treat ADHD at all if he is still in the mindset that ADHD folks are lazy."

 

[Ceke2002]

You could always fill your office space with shiny distractables & see how self reported ADHD patients respond. I am only half joking with that. With my own ADHD I am a lot better with it than I was in my 20s, for example I don't randomly wander off half way through conversations anymore, but if you placed me in a room with a lot of extra sensory input (books, pictures, ornaments, interestingly patterned carpet, etc, etc) that is likely to catch my eye and/or be a distraction, and then attempted to do a structured interview with me, well....'Ooh, look, shiny!'

 

[hebel]

Does anyone else have any details about how they approach their ADHD evaluations? This seemed to devolve into arguing about the addiction risk of stimulants.

@clausewitz2 , it looks like you typically go to the ACE+?

 

[Stagg737]

Does anyone else have any details about how they approach their ADHD evaluations? This seemed to devolve into arguing about the addiction risk of stimulants.

@clausewitz2 , it looks like you typically go to the ACE+?

I haven't used or really seen the ACE+ before so I looked it up. Seems like it's a fairly long and exhaustive form but the rating scales/system are basically just the DSM or ICD criteria and don't take a lot of the questions into the account.

@clausewitz2 (or anyone else who has used the ACE+), when you use this do you do it comprehensively or no? How long does it typically take to complete.

 

[clausewitz2]

I haven't used or really seen the ACE+ before so I looked it up. Seems like it's a fairly long and exhaustive form but the rating scales/system are basically just the DSM or ICD criteria and don't take a lot of the questions into the account.

@clausewitz2 (or anyone else who has used the ACE+), when you use this do you do it comprehensively or no? How long does it typically take to complete.

It is comprehensive but yes, it is based around DSM/ICD-10 criteria. The advantage of it is that a) it reminds you to cover a wide range of potentially confounding factors, b ) provides many specific examples of phenomenology and c) gives many examples of specific impairments that could be attributed to each question. you need to be probing for impairment AS an adult and AS a child and at school/work AND outside of it. On every question.

I often will have addressed many potential confounders by the time I get around to focusing down on ADHD. In terms of amount of time this takes, it depends. Sometimes people just say no to many of the questions or say they're very rare, which means it is over pretty quickly. Sometimes people say yes to everything but then kind of flail when asked to provide any examples of anything or it only ever happens at school or it has only caused a problem in the last year - this is also often over quickly. Generally it takes me 30-45 minutes for the ADHD specific part. It is not uncommon for me to address the preliminaries at initial intake and suggest we go through something more structured at the next appointment.

 

[hallowmann]

It is comprehensive but yes, it is based around DSM/ICD-10 criteria. The advantage of it is that a) it reminds you to cover a wide range of potentially confounding factors, b ) provides many specific examples of phenomenology and c) gives many examples of specific impairments that could be attributed to each question. you need to be probing for impairment AS an adult and AS a child and at school/work AND outside of it. On every question.

I often will have addressed many potential confounders by the time I get around to focusing down on ADHD. In terms of amount of time this takes, it depends. Sometimes people just say no to many of the questions or say they're very rare, which means it is over pretty quickly. Sometimes people say yes to everything but then kind of flail when asked to provide any examples of anything or it only ever happens at school or it has only caused a problem in the last year - this is also often over quickly. Generally it takes me 30-45 minutes for the ADHD specific part. It is not uncommon for me to address the preliminaries at initial intake and suggest we go through something more structured at the next appointment.

Reviewing it, the ACE+ is essentially how I was taught to evaluate for ADHD. It is certainly a bit more involved than what I always do, but covers the general framework of the conversation I use, and the main points. The bolded is something I find particularly helpful from an evaluation standpoint. Thanks for suggesting this, I had not actually reviewed it before.

 

[Stagg737]

Reviewing it, the ACE+ is essentially how I was taught to evaluate for ADHD. It is certainly a bit more involved than what I always do, but covers the general framework of the conversation I use, and the main points. The bolded is something I find particularly helpful from an evaluation standpoint. Thanks for suggesting this, I had not actually reviewed it before.

Agree with this. I feel like I largely do a lot of what the ACE+ has, but just don't go into as much depth in some areas (usually d/t time constraints). I do like some of the more specific questions like risk factors as well as the specific examples and it's nice to see the questions I've been asking are actually relevant. Also, I'll add that as someone with ADHD having everything laid out in an organized fashion seems like it would be extremely helpful both for evaluation and documentation.

 

[FlowRate]

It is comprehensive but yes, it is based around DSM/ICD-10 criteria. The advantage of it is that a) it reminds you to cover a wide range of potentially confounding factors, b ) provides many specific examples of phenomenology and c) gives many examples of specific impairments that could be attributed to each question. you need to be probing for impairment AS an adult and AS a child and at school/work AND outside of it. On every question.

I often will have addressed many potential confounders by the time I get around to focusing down on ADHD. In terms of amount of time this takes, it depends. Sometimes people just say no to many of the questions or say they're very rare, which means it is over pretty quickly. Sometimes people say yes to everything but then kind of flail when asked to provide any examples of anything or it only ever happens at school or it has only caused a problem in the last year - this is also often over quickly. Generally it takes me 30-45 minutes for the ADHD specific part. It is not uncommon for me to address the preliminaries at initial intake and suggest we go through something more structured at the next appointment.

I tried integrating ACE+ into my practice after you mentioned it because I probably see two ADHD evals per day on average. Or at least the ADHD symptoms part. The average person can't give more than one example and rarely a specific childhood example, even the ones who come across as inattentive conversationally (feel more "legit"). Sometimes I hear almost ver batim the same statements from folks and wonder if people are reading off of some "how to get prescribed adderall" website. There was one guy specifically who actually looked to be reading whenever he answered my questions, although that's not as common.

 

[clausewitz2]

I tried integrating ACE+ into my practice after you mentioned it because I probably see two ADHD evals per day on average. Or at least the ADHD symptoms part. The average person can't give more than one example and rarely a specific childhood example, even the ones who come across as inattentive conversationally (feel more "legit").

If someone is sort of on the edge and they feel "legit" in that way despite not having the greatest ability to recall examples, I generally call collateral. Occasionally this means I get to hear a lot more about how they met criteria, but honestly so far what usually happens is that I call that collateral doesn't endorse hardly any Vanderbilt items on the ADHD relevant subscales but does rate them highly on the depression/anxiety subscale or only reports impairment at school. The trouble with that interview I have with most people who I end up diagnosing with ADHD is more that they end up providing examples for somewhat related criteria because they quickly lose the thread of exactly what I asked them (if they processed it successfully in the first place).

I think usually people who genuinely have ADHD to the point they meet clinical threshold we use to call it a disorder are very well aware that they struggled and would prefer not to be able to recall the times they were embarassed or ashamed or humiliated or got in trouble because of those difficulties. They're usually not so lucky.

Sometimes I hear almost ver batim the same statements from folks and wonder if people are reading off of some "how to get prescribed adderall" website. There was one guy specifically who actually looked to be reading whenever he answered my questions, although that's not as common.

This started happening an awful lot to me when I started being more structured, especially when I say, "so can you give me an example of a time that caused a problem for you?" Haven't had anyone obviously reading anything off as they were answering my questions but I am pretty sure you are right in your speculations.

 

[WisNeuro]

This started happening an awful lot to me when I started being more structured, especially when I say, "so can you give me an example of a time that caused a problem for you?" Haven't had anyone obviously reading anything off as they were answering my questions but I am pretty sure you are right in your speculations.

This would happen a lot at the VA. Moreso for PTSD, where you would ask an open ended question about symptoms they were experiencing and they would go down the PTSD sx list in order as it appeared in the DSM, with very similar wording.

 

[clausewitz2]

This would happen a lot at the VA. Moreso for PTSD, where you would ask an open ended question about symptoms they were experiencing and they would go down the PTSD sx list in order as it appeared in the DSM, with very similar wording.

Yes! And sometimes these aren't even questions where it would be all that difficult to make up a compelling answer! Like, "so can you tell me about a time you lost something you needed for an activity?"

 

[Stagg737]

The trouble with that interview I have with most people who I end up diagnosing with ADHD is more that they end up providing examples for somewhat related criteria because they quickly lose the thread of exactly what I asked them (if they processed it successfully in the first place).

My ADHD evals often tend to run long when a patient is legit. I typically will ask a moderately open-ended question and then just let them talk. I've found that people have a fairly difficult time imitating the tangentiality of ADHD thought processes in moderate to severe cases. I also feel like there's a subset of people with legit ADHD who will intentionally keep their answers to clinical questions short because they get a bit embarrassed about rambling. I sometimes try and start some casual banter to see if their speech pattern changes if they become more relaxed.

This would happen a lot at the VA. Moreso for PTSD, where you would ask an open ended question about symptoms they were experiencing and they would go down the PTSD sx list in order as it appeared in the DSM, with very similar wording.

I've actually been surprised by how rare this has been at our VA. Almost everyone I've evaluated for PTSD has been pretty severe and it's been obvious that they're going through a bad time even before we really start the interview. On the plus side I am now an expert at placing referrals to our PTSD clinic.

Yes! And sometimes these aren't even questions where it would be all that difficult to make up a compelling answer! Like, "so can you tell me about a time you lost something you needed for an activity?"

Sometimes I hear almost ver batim the same statements from folks and wonder if people are reading off of some "how to get prescribed adderall" website.

Ask and you shall receive:

*Edited* I don't want to post images that obviously encourage this, but if you google @FlowRate 's quote there are literally dozens of threads answering this question on Reddit.

There are also a couple of non-reddit sources that are easily googled.

 

[FlowRate]

*Edited* I don't want to post images that obviously encourage this, but if you google @FlowRate 's quote there are literally dozens of threads answering this question on Reddit.

Yeah I was curious about it because I had heard about it in passing and ended up looking at a few websites while I was at work. Definitely a thing.

My not-serious tinfoil hat conspiracy is that the stimulant manufacturers are behind the websites like additudes and the popularization/destimatization of the ADHD diagnosis. It's big money.

 

[clausewitz2]

Yeah I was curious about it because I had heard about it in passing and ended up looking at a few websites while I was at work. Definitely a thing.

My not-serious tinfoil hat conspiracy is that the stimulant manufacturers are behind the websites like additudes and the popularization/destimatization of the ADHD diagnosis. It's big money.

Abbott invented mood trackers and the idea of a mood stabilizer when they introduced Depakote so this is not implausible to me at all.

 

[hallowmann]

Yeah I was curious about it because I had heard about it in passing and ended up looking at a few websites while I was at work. Definitely a thing.

My not-serious tinfoil hat conspiracy is that the stimulant manufacturers are behind the websites like additudes and the popularization/destimatization of the ADHD diagnosis. It's big money.

Just had a patient talk about using ADDitudes to find helpful ways to manage without meds. They had genuine ADHD since childhood that was effectively managed on low dose stimulants, but these were discontinued for personal patient reasons.

The visit was all over the place and all I was thinking was how are you functioning right now, and the answer was that they've molded their whole world around the expectation that they will lose things and lose track of what they were doing, and this was half managed by them and half by their family and coworkers. I put them back on their low-dose long-acting stimulant.

 

[Photoelectric19]

Is there any literature out there on people abusing their sertraline? (Semi-serious question).

I don't dispute that stimulants can be very helpful, but I doubt a couple weeks to confirm things is going to make or break things. A stimulant is not on the table, typically, on the first visit, but once things are confirmed it's fair game. Some people also don't want a stimulant. Not everyone wants to deal with all the rules of being on controlled substances, and I present that as part of my pros and cons discussion.

Of course, my training at an academic institution, much like OP's, was to be very conservative with stimulants. "Never prescribe stimulants on a first visit, always get collateral" was our mantra. The idea about ADHD not being an emergency unless there's a safety concern is also from my training. Thanks to this forum, yesterday I did step on myself and prescribe a small supply of stimulant to a new patient with reasonably classic ADHD who is treatment naïve, so I suspect this is just something to get used to.

I also, fun fact, have come a long way in terms of challenging my countertransference about ADHD. There was a time, long ago back in med school/early residency, when I quietly "didn't believe in" ADHD. Though I was aware it's a neurodevelopmental disorder, ADHD still occupied the same space in my mind as "poor parenting/chaos at home/bad kid syndrome," "undisciplined" and "lazy." After all, behavioral interventions are first line for kids, aren't they, and for adults, behavioral interventions are key as well. So I thought that a large part of the disorder was due to a failure of others to discipline kids and people to discipline themselves.

To be clear, I don't think that way anymore. I realize many cases of ADHD are too severe for behavioral interventions, and if opportunities for behavioral training in childhood were missed, there's only so much that can be done to make up for it.

Thank you. A part of me still thinks that a lazy, undisciplined is quite likely to answer affirmatively to some of the ADHD questions. Like, reluctance to start tasks that require sustained mental effort, anyone?

Glad you aren’t my psychiatrist. It’s unfortunate you treat people with ADHD, thank you for providing an example of how not to practice

 

[FlowRate]

It's clearly a sensitive subject when you wonder about whether we over-diagnose ADHD or, in other words, pathologize part of the normal spectrum of human behavior--which can include just simply preferring not to do hard stuff (low on conscientiousness = lazy/carefree/undisciplined/casual). It's understandable because people with ADHD have been unfairly called lazy prior to their diagnosis and in milder cases there's probably some internal conflict about pathology vs autonomy (as with any medical or mental health disorder that affects energy, attention, motivation, etc.)

 

[erg923]

Glad you aren’t my psychiatrist. It’s unfortunate you treat people with ADHD, thank you for providing an example of how not to practice

The most parsimonious explanation for some of the behavioral criteria for ADHD in the DSM is laziness/apathy/disinterest or other factors and/or psychosocial stressors. You don't have to like this statement, but anyone with any common sense knows it true.

It is poor practice to assume mental disorder is present in people coming to see you. Scientific thinking is to assume the opposite (the simplest possible explanation) until mental disorder becomes apparent as the only or most likely explanation for behavior.

 

[Photoelectric19]

Oh, for goodness sakes! Of course many of us think (and say) this. Stop being so coy. No shame here, son.

It is actually very, very reasonable to assume this/these fact vs the other. In fact, many, many people are indeed lazy. Only some of those lazy people will have an actual psychiatric disorder. If we have to rely on a cognitive heuristic ….. I would bet on "lazy" vs "psychiatrically disordered" anytime.

Further, is it statistically probable that 30% of your peds Medicaid population have the same (neurodevelopment) psychiatric disorder that is about estimated to be about 3-5% of the general population per extensive DSM survey research? If you believe that? Or maybe ****ty parents = ****ty behaving kids? I mean, come on folks?

I appreciate your biased opining as a psychologist, thank you for providing another example of how not to let stigma and my personal beliefs harm my future patients.

 

[WisNeuro]

Man, this thread got melodramatic in a hurry.

 

[aim-agm]

I appreciate your biased opining as a psychologist, thank you for providing another example of how not to let stigma and my personal beliefs harm my future patients.

To be frank, I doubt you will have future patients if this is how you accord yourself. Please refrain from polluting this otherwise useful thread. Alternatively, please continue to demonstrate your unfitness to participate in this discussion so as to expedite your account being banned.

 

[Stagg737]

I appreciate your biased opining as a psychologist, thank you for providing another example of how not to let stigma and my personal beliefs harm my future patients.

Might be good to wait until you get into med school to talk about “my future patients”. Also may want to avoid acting dismissive of those with far more experience before you even start the journey.