Differential diagnosis resources for ADHD vs trauma vs autism

[borne_before]

The main selling point of her book seems to be "it's okay to regularly drink alcohol during pregnancy!", which did not go over well with people who do fetal health research, I mean, is one or two drinks during pregnancy going to doom your baby? Probably not. Does the science overwhelmingly indicate that it's best not to drink during pregnancy, especially because people tend to underestimate how much they drink? Yes. Is it irresponsible to suggest that women should drink regularly during pregnancy as a matter of course? IMO, yes--there's tons of potential risks introduced with very little benefit.

That's not an accurate statement. It's part of it. But, I took it as - a glass of wine here or there isn't going to give your kid FASD. It's like saying the Bible is about a guy in a whale.

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[futureapppsy2]

That's not an accurate statement. It's part of it. But, I took it as - a glass of wine here or there isn't going to give your kid FASD. It's like saying the Bible is about a guy in a whale.

She says it's okay to drink alcohol approximately daily during the second and third trimester and around once or twice a week during the first trimester--that's more than an occasional glass of wine, and different from what every public health agency and the strong majority of doctors will recommend. Will this cause a massive epidemic of classical FASD? No, likely not. Is it advisable based on the literature? Also no. FASD is far from the only risk that comes with alcohol use during pregnancy, and studies have repeatedly shown that people will, for example, give themselves more than 8 ounces of wine but call it "one glass." Like I said, it's not evidence-based to say a single glass of wine will doom a baby, but it's also not evidence-based to say regular drinking during pregnancy is recommended or risk-free.

You say we can't trust researchers, because they have bias and things to sell, and yet you ignore all the free press she got by saying "occasional drinking during pregnancy isn't that bad." Come on, that's a hundred free headlines at least. Also, she drank lightly during pregnancy--does that not create likely bias of wanting to justify what she did was "not risky after all"?

 

[borne_before]

Hey @futureapppsy2 and @ClinicalABA ,

Those milestones weren’t from her. They’re from the slp literature - btw the new American academy of pediatrics guidelines didn’t consult any when developing them (both my parents are SLPs).

But that’s not why I tagged y’all, I just realized something and you deserve more from me: I’m in the midst of packing for a move (movers come next Saturday), putting lipstick on a pig (fixing up the old house for a sale - my soft academic hands are thrashed from hanging new metal siding and removing a tree at the new place ), and recovering from whatever brand of kennel cough the kids brought home last week (Wife is sick now), that I just don’t have the bandwidth to thoughtfully and carefully read your responses and reply in kind.

Basically, I’ve learned that stress impairs my ability respond in the good faith that y’all deserve.

I suspect that’s why my original post was more controversial than it should have been - It deserves more nuance and crafting and for forethought. I’m gonna put a pin in my replies until the dust settles and can honor you and your effort with more thoughtful responses. But I really do appreciate your perspective.

I promise your replies really do get consideration from me and appreciate your good faith. I’ll come back to them.

 

[smalltownpsych]

I’m not sure exactly what you guys are arguing about here with the Emily stuff and I stay away from the under 5 kids, but what I will say is that I see fetal etoh exposure as probably being a bigger problem than we realize. Granted this is anecdotal, but I have seen a surprising number of patients with clinically significant splits between verbal and visualspatial abilities that manifests in difficulties across the board and one thread of connection are mothers that like the “occasional glass of wine” and the fact that I know that they like wine kind of says it all. I recall that there is some research on fetal alcohol effects and connection to learning disabilities but I think that we tend to focus on the most extreme examples and as a society we are a little uncomfortable looking at just how much we cause damage to kids. I see a similar dynamic play out with adopted kids. Some of why these topics are of interest to me is that I work with young adults who are still affected because of some of these early developmental experiences whether prenatal or postnatal.

 

[smalltownpsych]

The logical conclusion to this is that ANY research is bad/faked/untrustworthy. What then are we left with when identifying truths in our world? Appeal to emotion? Appeal to authority? Picking a different method for each truth you want to identify, based on a priori beliefs about what those truths should be. Whatever- topic for another thread.

In regards to developmental norms, the typical "cut-offs" we see (e.g., "walking by 15 months"; "first words by 12 months"; "multiple word speech by 24 months") should be used as screening tools. If the behavior isn't seen by that age, the child is a few SDs from the average, and thus their MAY be a problem. Screening tools should produce a lot of false positives, as the alternative would lead to real delays not being addressed. Most kids are walking by 15 months (and most even sooner). A small proportion aren't. Of that small proportion that aren't, a portion has some has some identifying condition that is leading to their lack of independent walking, and would benefit from additional evaluation and intervention.
by having some generally agreed upon milestone age (which any well educated professional should understand is a limit on what is statistically normal and needs to be interpreted in the context of the variation in the distribution from which it is derived), we can then mete out services and resources (in this case, federally mandated EI/birth-to-three services) in a manner that ensure those who need it, get it, while also minimizing the number of children who don't need it but do get. As a society, we as a whole have identified this as the desired way of doing things, and these milestones are just a tool for achieving that ends.

As to "p-hacking" of developmental milestone research- really? These published milestones haven't changed much, if at all, over the past many years. Plus- they are something that we (lay people included) can see with our own damn eyes- most of our kids and our families/friends' kids walked starting talking by 12 mos, walked by 15 (at the latest),etc. This is a case where we have lot of naturalistic data supporting the published stuff. I find it very hard to believe that you (and I respect you) believe there are these conniving researchers faking (or judiciously evaluating) data and stats to produce purposefully incorrect conclusions regarding early development, grinning wildly as they cash their checks from "BIG EI" lobbyists. That's just adding "controversy" where there is- at best- some mild professional disagreement due to so slightly non overlapping data at the extreme ends of the distribution. I'm a lot more skeptical than the next guy. That doesn't mean that I don't believe everything I read, but rather that I have equipped myself with the tools to evaluate what I read and (in the case of a research article) understand enough about what's going on to determine if what is said in the conclusion could be and is supported by what is said in the methods and results.

Just wanted to say that this is a great post. How to critically analyze and utilize the research in an effective way is such a key component of a psychologist skill set and you captured it well.

 

[cara susanna]

I just read that Sia had a neuropsych evaluation that resulted in her being diagnosed with ASD and was supposedly 18 hrs. Is that typical for ASD? I don't do them but that seems VERY long to me.

 

[WisNeuro]

I just read that Sia had a neuropsych evaluation that resulted in her being diagnosed with ASD and was supposedly 18 hrs. Is that typical for ASD? I don't do them but that seems VERY long to me.

That's insane, but there are definitely some people who pad their billing. Like, I've seen someone bill for 8 hours of testing time for a non-forensic dementia case. My battery for a similar case would be 1.5-2 hrs of testing.

 

[AcronymAllergy]

I just read that Sia had a neuropsych evaluation that resulted in her being diagnosed with ASD and was supposedly 18 hrs. Is that typical for ASD? I don't do them but that seems VERY long to me.

I've once or twice heard of an eval lasting that long, but I think they were invariably forensic. I don't even know what tests I'd give to take up 18 hours. Maybe the eval included of multi-hour periods of behavioral observations in naturalistic environments...?

 

[futureapppsy2]

I just read that Sia had a neuropsych evaluation that resulted in her being diagnosed with ASD and was supposedly 18 hrs. Is that typical for ASD? I don't do them but that seems VERY long to me.

Yeah, that's excessive. Also, tbh, neuropsych isn't really needed in ASD assessment, unless there are other concerns for neurological disease or injury. People label things as "neuropsych evals" because they think it's "psychology but science" not really understanding that neuropsych is more specific for that. For a typical adult ASD eval, we would do a structured clinical interview (bonus if you can have the parents there), a general psych/behavior rating scale for the individual and informants, a social skills rating scale, sensory abnormalities rating scale, IQ/cognitive testing, speech/language testing (we had SLPs as a permanent part of the clinic, so this may be more optional if you don't), and an ADOS. We would also try to get retrospective childhood reports if we couldn't get that from the parents during the structured interview and perhaps personality assessment, occupational therapy assessment, and/or medical consultation depending on the needs and particular concerns and rule-outs. We typically deliberately spread assessments out over multiple days to get multiple days of behavioral observation, but the total in-clinic time for the patient was maybe 9-12 hours, depending if additional testing was needed, how long the structured interview took, etc.

 

[AcronymAllergy]

Yeah, that's excessive. Also, tbh, neuropsych isn't really needed in ASD assessment, unless there are other concerns for neurological disease or injury. People label things as "neuropsych evals" because they think it's "psychology but science" not really understanding that neuropsych is more specific for that. For a typical adult ASD eval, we would do a structured clinical interview (bonus if you can have the parents there), a general psych/behavior rating scale for the individual and informants, a social skills rating scale, sensory abnormalities rating scale, IQ/cognitive testing, speech/language testing (we had SLPs as a permanent part of the clinic, so this may be more optional if you don't), and an ADOS. We would also try to get retrospective childhood reports if we couldn't get that from the parents during the structured interview and perhaps personality assessment, occupational therapy assessment, and/or medical consultation depending on the needs and particular concerns and rule-outs. We typically deliberately spread assessments out over multiple days to get multiple days of behavioral observation, but the total in-clinic time for the patient was maybe 9-12 hours, depending if additional testing was needed, how long the structured interview took, etc.

Impressive. I'm pretty sure if anyone here does adult ASD evals, they're like 2 hours and probably consist primarily of internet checklists.

 

[borne_before]

Yeah, that's excessive. Also, tbh, neuropsych isn't really needed in ASD assessment, unless there are other concerns for neurological disease or injury. People label things as "neuropsych evals" because they think it's "psychology but science" not really understanding that neuropsych is more specific for that. For a typical adult ASD eval, we would do a structured clinical interview (bonus if you can have the parents there), a general psych/behavior rating scale for the individual and informants, a social skills rating scale, sensory abnormalities rating scale, IQ/cognitive testing, speech/language testing (we had SLPs as a permanent part of the clinic, so this may be more optional if you don't), and an ADOS. We would also try to get retrospective childhood reports if we couldn't get that from the parents during the structured interview and perhaps personality assessment, occupational therapy assessment, and/or medical consultation depending on the needs and particular concerns and rule-outs. We typically deliberately spread assessments out over multiple days to get multiple days of behavioral observation, but the total in-clinic time for the patient was maybe 9-12 hours, depending if additional testing was needed, how long the structured interview took, etc.

In most cases - adult ASD evals are usually about getting someone help from their department of developmental disabilities, issues with guardianship, etc. In those cases, I like what you say.

But for Sia, someone who is independent and shows little adaptive impairment, you cannot adequately dx autism for an initial diagnosis in adulthood without personality testing, IMO.

Wonder if they did a lot of personality testing.

 

[WisNeuro]

In most cases - adult ASD evals are usually about getting someone help from their department of developmental disabilities, issues with guardianship, etc. In those cases, I like what you say.

But for Sia, someone who is independent and shows little adaptive impairment, you cannot adequately dx autism for an initial diagnosis in adulthood without personality testing, IMO.

Wonder if they did a lot of personality testing.

My guess is that they did a lot of garbage projective testing.

 

[futureapppsy2]

In most cases - adult ASD evals are usually about getting someone help from their department of developmental disabilities, issues with guardianship, etc. In those cases, I like what you say.

But for Sia, someone who is independent and shows little adaptive impairment, you cannot adequately dx autism for an initial diagnosis in adulthood without personality testing, IMO.

Wonder if they did a lot of personality testing.

Yeah, Sia is the type of client for whom we probably would have done personality testing.

 

[ClinicalABA]

I just read that Sia had a neuropsych evaluation that resulted in her being diagnosed with ASD and was supposedly 18 hrs. Is that typical for ASD? I don't do them but that seems VERY long to me.

I 've seen similar lengths with children (12+ hours, 20+ page report) from one of the bigger hospitals in Boston. Kid was late elementary/middle school. Craziness. I bet the similarities begin at being a private pay client (or huge premium boutique insurance plan with no pre-auth required). I bet her eval was heavy with non-critical assessments (projectives; every neropsych-y test and subtest out there).

 

[erg923]

I 've seen similar lengths with children (12+ hours, 20+ page report) from one of the bigger hospitals in Boston. Kid was late elementary/middle school. Craziness. I bet the similarities begin at being a private pay client (or huge premium boutique insurance plan with no pre-auth required). I bet her eval was heavy with non-critical assessments (projectives; every neropsych-y test and subtest out there).

A Medical Director at our org recently had a preauth request for 72 hours of Psychological Testing to assess an adult for possible ASD (and ADHD?).

I can only assume this was made up (maybe to appease the patient?) and they didn't really want to see them. They asked for 9 hours alone to do and interpret a WAIS-IV, btw. Have to assume its a joke at that point but cant understand the time filling auth paperwork for said joke?

They denied it all in hopes of triggering a telephonic Peer-to-Peer and a possible quality of care or fraud submission to corporate. I'm sure it triggered a quality of care/fraud investigation anyway though.

 

[futureapppsy2]

I 've seen similar lengths with children (12+ hours, 20+ page report) from one of the bigger hospitals in Boston. Kid was late elementary/middle school. Craziness. I bet the similarities begin at being a private pay client (or huge premium boutique insurance plan with no pre-auth required). I bet her eval was heavy with non-critical assessments (projectives; every neropsych-y test and subtest out there).

I can't see that much time for a kid being justifiable (or useful for anything but $$$$), tbh.

 

[borne_before]

I can't see that much time for a kid being justifiable (or useful for anything but $$$$), tbh.

I call those types of reports "Assessment Masturbation" because they're clearly about showing how smart the evaluator is.

 

[WisNeuro]

I call those types of reports "Assessment Masturbation" because they're clearly about showing how smart the evaluator is.

If smart = wordy, wasteful, inefficient, and possibly unethical, I agree with you.

 

[ClinicalABA]

I call those types of reports "Assessment Masturbation" because they're clearly about showing how smart the evaluator is.

It was from a teaching hospital. At least 5 different signatures on the report. Issue in question was school refusal!

 

[MCParent]

If smart = wordy, wasteful, inefficient, and possibly unethical, I agree with you.

When I had my pp I was asked multiple times for second opinions on the OOP cost of testing for normal evals after pt’s parents were quoted 4-6x what I charged. All of those people were RICH and in fields totally unrelated to health care, so I assume the original psychs were trying to bilk them.

 

[WisNeuro]

When I had my pp I was asked multiple times for second opinions on the OOP cost of testing for normal evals after pt’s parents were quoted 4-6x what I charged. All of those people were RICH and in fields totally unrelated to health care, so I assume the original psychs were trying to bilk them.

Yeah, the peds landscape is so much worse than the adult one. I see some crazy stuff put there from people like "school neuropsychologists" doing lengthy assessments, qEEG, and other pseudoscience. Usually referring back to themselves to deliver neurofeedback for some new form of ADHD that only their tests can measure.

 

[AcronymAllergy]

Yeah, the peds landscape is so much worse than the adult one. I see some crazy stuff put there from people like "school neuropsychologists" doing lengthy assessments, qEEG, and other pseudoscience. Usually referring back to themselves to deliver neurofeedback for some new form of ADHD that only their tests can measure.

"Your child has a newly-discovered (by me) version of ADHD without hyperactivity/impulsivity or inattention. It's mostly characterized by sometimes not wanting to do homework or clean their room. For four easy payments of $2999, I can remove the diagno...I mean cure it.

Also, feel free to peruse my proprietary collection of essential oils and dietary supplements on your way out of the office.

-Dr. AA, Ph.D, MBA, MBMD, MMPI, MCMI, WAIS, WMS"

 

[MCParent]

"Your child has a newly-discovered (by me) version of ADHD without hyperactivity/impulsivity or inattention. It's mostly characterized by sometimes not wanting to do homework or clean their room. For four easy payments of $2999, I can remove the diagno...I mean cure it. write letters to recommend extended time and other accommodations for the SATs, MCAT, or any other tests; approve an emotional support animal; and demand scripts for stimulants (and maybe a lil something for you?).

Also, feel free to peruse my proprietary collection of essential oils and dietary supplements on your way out of the office.

-Dr. AA, Ph.D, MBA, MBMD, MMPI, MCMI, WAIS, WMS"

Fixed that for you

 

[borne_before]

"Your child has a newly-discovered (by me) version of ADHD without hyperactivity/impulsivity or inattention. It's mostly characterized by sometimes not wanting to do homework or clean their room. For four easy payments of $2999, I can remove the diagno...I mean cure it. write letters to recommend extended time and other accommodations for the SATs, MCAT, or any other tests; approve an emotional support animal; and demand scripts for stimulants (and maybe a lil something for you?).

Also, feel free to peruse my proprietary collection of essential oils and dietary supplements on your way out of the office.

-Dr. Daniel Amen, MD, Ph.D, MBA, MBMD, MMPI, MCMI, WAIS, WMS, MRI, FMRI"

@MCParent Fixed that a little more.

 

[MCParent]

@MCParent Fixed that a little more.

I’ve heard about psychs pushing their MLM garbage on clients. The absolute wrath I would have if I had ever found out a trainee of mine was involved in that.

 

[Ollie123]

I’ve heard about psychs pushing their MLM garbage on clients. The absolute wrath I would have if I had ever found out a trainee of mine was involved in that.

Had to block a gal I used to work with on FB because she just jammed up my feed with constant posts about essential oils. No idea if she was pushing it on patients but it wouldn't surprise me.

She graduated from a clinical science program. She has published RCTs and methodology papers. Her PhD mentor is quite literally one of the most rigorous scientists I have met. I have no earthly idea where it came from.

 

[cara susanna]

Honestly I feel like a lot of the sketchier psychotherapies are MLM.

 

[WisNeuro]

Honestly I feel like a lot of the sketchier psychotherapies are MLM.

Like EMDR/Brainspotting? "Come do this expensive training and then buy our expensive placebo machine. Then do more expensive training to become a trainer! Then you can charge people exorbitant fees to sell more snakeoil....err I mean groundbreaking treatments!"

 

[borne_before]

Honestly I feel like a lot of the sketchier psychotherapies are MLM.

I know of several phds who have fallen prey to MLMs. During my postdoc consortium, we had a training at a neuro clinic. They had a glass display case with essential oils. She was also talking about this software that basically did all the work for her.

 

[cara susanna]

Like EMDR/Brainspotting? "Come do this expensive training and then buy our expensive placebo machine. Then do more expensive training to become a trainer! Then you can charge people exorbitant fees to sell more snakeoil....err I mean groundbreaking treatments!"

Yes, and IFS too

 

[smalltownpsych]

When I was getting my business started and had the time, I spent some time “networking” with other professionals. There seemed to be some personality types that are drawn to and promote MLM and also seem to like to network a lot. Interacting with people who are excited about gimmicky new solutions is painful for me. I am glad our business is doing just fine with word of mouth referrals and a lot of those are coming from other busy professionals who are more into quality than shiny and new.

 

[Ollie123]

There seemed to be some personality types that are drawn to and promote MLM and also seem to like to network a lot.

People with lots of free time because their business/practice is not very successful and who you can smell the desperation on from across the room?

 

[Doctor Eliza]

I just received an adult ASD assessment report that used the MIGDAS-2 rather than the ADOS-2. Anyone have experience with this measure? Or thoughts? Thanks!

 

[MCParent]

Honestly I feel like a lot of the sketchier psychotherapies are MLM.

I mean, in fairness, the history of most of the main theories look like a bit that too 😂

 

[Adeel Sarwar]

It's great that you're expanding your practice to work with a broader range of clients. To build competency, consider professional development, literature review, mentorship, observation, networking, case studies, and ongoing consultation. Keep up the good work!

 

[Adeel Sarwar]

I just received an adult ASD assessment report that used the MIGDAS-2 rather than the ADOS-2. Anyone have experience with this measure? Or thoughts? Thanks!

I haven't personally used the MIGDAS-2, but it's interesting that it was chosen over the ADOS-2 for the assessment. The MIGDAS-2, from what I know, is designed to assess various aspects of autism spectrum disorder in adults, and it's possible that the clinician had specific reasons for selecting it over the ADOS-2.

If anyone here has direct experience with the MIGDAS-2 or insights on its utility in adult ASD assessments, please share your thoughts.

 

[PsyDr]

I haven't personally used the MIGDAS-2, but it's interesting that it was chosen over the ADOS-2 for the assessment. The MIGDAS-2, from what I know, is designed to assess various aspects of autism spectrum disorder in adults, and it's possible that the clinician had specific reasons for selecting it over the ADOS-2.

If anyone here has direct experience with the MIGDAS-2 or insights on its utility in adult ASD assessments, please share your thoughts.

Are you going to use that information in your own commercial endeavors in AI based assessment?

 

[psyduckies]

I saw the MIGDAS given once during internship. From my understanding it started to be used more during COVID era because of face masks. From what I was told the ADOS can’t have face masks on, the MIGDAS can. When you’re in a COVID hot spot, that made some move towards the MIGDAS (at least that is what I gathered from the few I had heard who had given both the ADOS and MIGDAS frequently). Could be one reason it was chosen .

As for administration wise, it felt less structured than the ADOS. It felt to get more at some of the repetitive behaviors/restricted interests than the ADOS. Take that with a grain of salt, as ASD testing isn’t a heavy emphasis of mine (I’ve seen 6 or so ADOS and 1 MIGDAS so it’s pretty limited).