primary care doctors cherry picking ADHD patients?

[vistaril]

Anyone have this going on in their area? It has the potential to be a bigger problem here for outpt psych....

Basically these practices have *completely stopped* seeing anything but ADHD cases.(one also does suboxone and botox I think). They don't write lisinopril for blood pressure, metformin for DM2, don't do physicals, won't treat a UTI, etc......they won't even treat other psychiatric conditions. It's ALL attention/focus problems.
It's a problem for me/us because it has the potential to 'steal' some of these patients which typically are the best patients for any outpt practice. Because they have the potential to be relatively quick visits which are sources of stable and constant income over time for a practice(which is why these practices want to cherry pick them of course). From a day to day practical sense, it's also not uncommon to steal a few minutes from a stable adhd pt who is doing great and spend a few more minutes with that unstable borderline and needs more time.....

It's not so much that I don't think adult pcps should be treating any adhd(it's not brain surgery and Im sure some do it better than many psychiatrists).....it's just frustrating.

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[nexus73]

It sounds frustrating. A PCP clinic in town was like that; I actually thought it was a new psychiatrist at first because of the ADHD/addiction focus. I think these docs lack the boundary training psychiatrists have, which can lead to progressive crossings and ultimately boundary violations.

 

[notdeadyet]

My old town had a PCP doing just minor derm stuff. Made bank.

 

[birchswing]

That would seem awkward to advertise. An ADHD specialist with no special training in ADHD.

I have seen people who specialize in testing for the purpose of writing accommodations letters for ADHD and learning disabilities.

 

[F0nzie]

Practicing outside of their scope sounds like a nice big target for sanctions or a lawsuit.

 

[sunlioness]

When I had my solo practice, there was a woman who rented office space in the same building as me. She represented herself as a therapist, or at least she didn't correct that assumption. And I assumed she was a psychologist. She came down to introduce herself one day and claimed that she did testing for ADD, could she refer her clients to me for meds? Well, of course she could.

Come to find out when her first patient came that the "testing" was just some screening tools she'd printed off the internet. She was actually someone who'd been diagnosed and prescribed stimulants herself and felt this experience was so life changing that it was her job to identity ADHD in the masses and get them stimulants. Turned out she wasn't a licensed therapist of any kind. She was some sort of life coach type thing. Then there was the day she burst in my office unannounced and told me she had a suicidal patient in her office. What should she do? I needed to come up and see this patient and solve her problem for her.

I just stared at her coolly and said three numbers, 9-1-1.




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[Mad Jack]

Practicing outside of their scope sounds like a nice big target for sanctions or a lawsuit.

Is it actually outside of their scope though? Seems pretty standard for PCPs to do ADD, who's to say they can't just do nothing but ADD. The only real issue would be if they misrepresented their training in some way.

 

[erg923]

Is it actually outside of their scope though? Seems pretty standard for PCPs to do ADD, who's to say they can't just do nothing but ADD. The only real issue would be if they misrepresented their training in some way.

Who's diagnosing it, though?

Problems with attention and/or hyperactive behavior (in adults or children) is about specific as "I have a cough." I hope people aren't under the delusion that PCP are doing in-depth differential diagnostic interviews, history taking/gathering for these cases. Not too mention rule-out flat out malingering and secondary gain.

 

[MacDonaldTriad]

If someone sucked all of the adult ADHD cases out of a practice and this included all of the stimulant seekers, I would see it as a blessing.

 

[Salpingo]

Anyone have this going on in their area? It has the potential to be a bigger problem here for outpt psych....

Basically these practices have *completely stopped* seeing anything but ADHD cases.(one also does suboxone and botox I think). They don't write lisinopril for blood pressure, metformin for DM2, don't do physicals, won't treat a UTI, etc......they won't even treat other psychiatric conditions. It's ALL attention/focus problems.
It's a problem for me/us because it has the potential to 'steal' some of these patients which typically are the best patients for any outpt practice. Because they have the potential to be relatively quick visits which are sources of stable and constant income over time for a practice(which is why these practices want to cherry pick them of course). From a day to day practical sense, it's also not uncommon to steal a few minutes from a stable adhd pt who is doing great and spend a few more minutes with that unstable borderline and needs more time.....

It's not so much that I don't think adult pcps should be treating any adhd(it's not brain surgery and Im sure some do it better than many psychiatrists).....it's just frustrating.

How is that sustainable? To fill a 40 hr/week practice with 15 minute monthly med checks, you would need 640 ADHD patients. I don't know any community that could support that (although maybe if it's a family med person seeing kids/adolescents?). And if you consider the comorbidity of ADHD and depression/anxiety/substance abuse, you'll inevitably hit 100+ "complicated" psych patients. You can SAY you don't see borderline patients if you don't do a comprehensive psych eval, but that doesn't change the fact that you HAVE borderline patients.

It sounds like this is the stimulant equivalent of a "Dr 4-20" marijuana dispenser, and I'm assuming this hypothetical MD would have to develop a reputation as a semi-legal drug dealer to get cash-paying clients, inviting some shady costumes and DEA attention. I wouldn't worry about it.

 

[Shikima]

Who's diagnosing it, though?

Problems with attention and/or hyperactive behavior (in adults or children) is about specific as "I have a cough." I hope people aren't under the delusion that PCP are doing in-depth differential diagnostic interviews, history taking/gathering for these cases. Not too mention rule-out flat out malingering and secondary gain.

There's an antibiotic for that cough.

 

[smalltownpsych]

There's an antibiotic for that cough.

Great. I think I'll head down to the ER to get it.

 

[smalltownpsych]

Great. I think I'll head down to the ER to get it.

I decided not to go down there because I didn't want to wait behind all those people having real emergencies like sore throats and fevers.

 

[Bartelby]

How is that sustainable? To fill a 40 hr/week practice with 15 minute monthly med checks, you would need 640 ADHD patients.

Exactly. This whole scenario sounds implausible. If someone is actually doing it keep in mind that unlike for someone focusing only on minor cosmetic derm procedures the DEA would likely take an interest in someone prescribing nothing but stimulants all day long.

 

[vistaril]

If someone sucked all of the adult ADHD cases out of a practice .

It's not a blessing for those of us who work in private practice and depend on our codes/collections for our livelihood......anyone who works in private practice(and isn't getting a paycheck from a govt entity or academia) will tell you that ADHD patients are very important to the practice's bottom line.

 

[vistaril]

Who's diagnosing it, though?

Problems with attention and/or hyperactive behavior (in adults or children) is about specific as "I have a cough." I hope people aren't under the delusion that PCP are doing in-depth differential diagnostic interviews, history taking/gathering for these cases. Not too mention rule-out flat out malingering and secondary gain.

All these are 'perfect world' issues/scenarios......the real world and the perfect world occasionally intersect, but not usually.......and when they do it's sometimes not cost-effective anyways.

 

[vistaril]

Practicing outside of their scope sounds like a nice big target for sanctions or a lawsuit.

I'm not sure(in general) it's 'out of scope'.....but the fact that they are cherry picking is what pisses me off.

 

[Shikima]

It's not a blessing for those of us who work in private practice and depend on our codes/collections for our livelihood......anyone who works in private practice(and isn't getting a paycheck from a govt entity or academia) will tell you that ADHD patients are very important to the practice's bottom line.

It's not to mine.

 

[vistaril]

How is that sustainable? To fill a 40 hr/week practice with 15 minute monthly med checks, you would need 640 ADHD patients. I don't know any community that could support that (although maybe if it's a family med person seeing kids/adolescents?). And if you consider the comorbidity of ADHD and depression/anxiety/substance abuse, you'll inevitably hit 100+ "complicated" psych patients. You can SAY you don't see borderline patients if you don't do a comprehensive psych eval, but that doesn't change the fact that you HAVE borderline patients.

It sounds like this is the stimulant equivalent of a "Dr 4-20" marijuana dispenser, and I'm assuming this hypothetical MD would have to develop a reputation as a semi-legal drug dealer to get cash-paying clients, inviting some shady costumes and DEA attention. I wouldn't worry about it.

I'm worried about it because I see the patients flowing away.....and 640 patients in an area of > 1 million isn't that tough.

 

[vistaril]

It's not to mine.

you work in a general outpt psych private practice and don't see a decent percentage of adhd cases? If so, Looking at the nationwide numbers of outpt visits/dx, that's a bit atypical....

 

[Shikima]

you work in a general outpt psych private practice and don't see a decent percentage of adhd cases? If so, Looking at the nationwide numbers of outpt visits/dx, that's a bit atypical....

I have 2 on my case load. I throw the drug seekers out. I'm also known for not being the candy man in the community. I do plenty of insomnia related sleep disorders while being known for the guy to send geriatrics to see - the Gero fellowship locally has asked me to open my clinic to allow their fellow to join me in clinic.

 

[vistaril]

I have 2 on my case load. I throw the drug seekers out. I'm also known for not being the candy man in the community. I do plenty of insomnia related sleep disorders while being known for the guy to send geriatrics to see - the Gero fellowship locally has asked me to open my clinic to allow their fellow to join me in clinic.

I guess my point was that on a per minute per code basis the typical ADHD patient takes less time than the typical mood or anxiety d/o patient(or insomnia or cognitive d/o patient). In any given time interval I'm going to be able to see more ADHD patients than other types of patients. And that means more money. Other clinicians taking some of this easier source of revenue is not a good thing from a $ sense.

Im different in that I like treating ADHD too. I think a lot of psychs do....partly for the reasons above and partly because we see the functional improvements in a patients day to day live. I see some drug seekers, but the majority of my adhd patients I don't put in that category.

 

[Salpingo]

I guess my point was that on a per minute per code basis the typical ADHD patient takes less time than the typical mood or anxiety d/o patient(or insomnia or cognitive d/o patient). In any given time interval I'm going to be able to see more ADHD patients than other types of patients. And that means more money. Other clinicians taking some of this easier source of revenue is not a good thing from a $ sense.

Im different in that I like treating ADHD too. I think a lot of psychs do....partly for the reasons above and partly because we see the functional improvements in a patients day to day live. I see some drug seekers, but the majority of my adhd patients I don't put in that category.

Are you referring to something like this: http://www.focus-md.com/ ?

I think that's a legitimate practice model, but they're providing concierge service, "helping" with insurance [out-of-network benefits], making themselves available by email and presumably providing some wraparound services (school advocacy, testing, etc.) They're not seeing patients on a "per minute per code basis", and comparing their model to a community clinic is really apples to oranges.

If that's your area of interest, it looks like the practice above franchises, although I'm guessing they would want someone with child experience as well. As a psychiatrist, you would have to market yourself as capable of dealing with the anxiety and depression issues that are co-morbid with adult ADHD.

your calculations are way off as you're not factoring new patient evals. there is a pcp who had an ADD clinic in my town who does 60min evals for $290 and 20 minute follow ups are $210. she gives a discount if paying in cash... (as opposed to card or check)

That's true, I was thinking of a "full" practice, but presumably there would always be people entering and leaving. My main point was that to create a practice that large, and assuming 25-33% co-morbidity with other psychiatric conditions (as well as the developmental issues), you're going to wind up with A LOT of complicated patients. The alternative would be to willfully ignore the other symptoms before they spring up and essentially become a drug dealer.

Also, was the PCP also seeing children? Because my sense of adult ADHD is that its still a relatively under treated/unrecognized entity. Most of the people I know who specialize in it supplement their time with research (and probably make more giving talks or writing articles for pharma anyway).

 

[Salpingo]

Practicing outside of their scope sounds like a nice big target for sanctions or a lawsuit.

Pediatricians and child neurologists treat children's ADHD, and adult internists treat anxiety and depression. Depending on geography, PCPs treating ADHD could be the STANDARD of care. I'm having a hard time envisioning a lawsuit involving treatment of ADHD that would lead to significant damages. Maybe someone with a known history of bipolar that was given an egregious amount of stimulants, but I know patients treated by psychiatrists who have made the same mistake.

The biggest issue would probably be shoddy history-taking or documentation, but that's not specialty-dependent.

 

[PistolPete]

Pediatricians and child neurologists treat children's ADHD, and adult internists treat anxiety and depression. Depending on geography, PCPs treating ADHD could be the STANDARD of care. I'm having a hard time envisioning a lawsuit involving treatment of ADHD that would lead to significant damages. Maybe someone with a known history of bipolar that was given an egregious amount of stimulants, but I know patients treated by psychiatrists who have made the same mistake.

The biggest issue would probably be shoddy history-taking or documentation, but that's not specialty-dependent.

Courts have moved away from a geographic standard and use a national standard since certain communities only have one physician in a particular area who automatically sets the local standard but who may not be practicing prudently.

 

[Shikima]

Pediatricians and child neurologists treat children's ADHD, and adult internists treat anxiety and depression. Depending on geography, PCPs treating ADHD could be the STANDARD of care. I'm having a hard time envisioning a lawsuit involving treatment of ADHD that would lead to significant damages. Maybe someone with a known history of bipolar that was given an egregious amount of stimulants, but I know patients treated by psychiatrists who have made the same mistake.

The biggest issue would probably be shoddy history-taking or documentation, but that's not specialty-dependent.

Exactly. I saw a girl, only a few times who's complaining of text book hypomania symptoms minus the decreased need for sleep. Her thinking was much like it was before and had been prescribed stimulants by her PCP. After 45 mins of education and praising her for giving out a lot of details, got her started on a better treatment plan including a mood stabilizer.

 

[whopper]

Courts have moved away from a geographic standard and use a national standard since certain communities only have one physician in a particular area who automatically sets the local standard but who may not be practicing prudently.

True but to be more specific it's a "reasonable physician" standard, at least from the forensic articles I've read. In short still consider it a national standard. E.g. if the APA says to do something it's in your CYA interest to do it even if no other local doctor's doing it cause that's the ammo that can be used against you.

A problem here is there's no blinking neon light telling docs what the standard is in their locality-reasonable physician standard vs standard of care (which includes a local geographic definition).

 

[whopper]

ADHD easy patients? IMHO yes and no. If the patient's honest and really has ADHD yes. Where I used to practice in Ohio I had strong reason to believe I was approached by a lot of bull$hitters.

Where I'm at in St. Louis so far none of the ADHD people I've had (and I've only been doing private practice about 5 weeks) seems to have been faking. How can I tell? Virtually every patient when asked to try Wellbutrin first has been open to it.

A BEEG problem in Missouri is it's the only state in the country without a central pharmacy so I can't tell if the patient is getting controlled substances elsewhere.

 

[smalltownpsych]

ADHD easy patients? IMHO yes and no. If the patient's honest and really has ADHD yes. Where I used to practice in Ohio I had strong reason to believe I was approached by a lot of bull$hitters.

Where I'm at in St. Louis so far none of the ADHD people I've had (and I've only been doing private practice about 5 weeks) seems to have been faking. How can I tell? Virtually every patient when asked to try Wellbutrin first has been open to it.

A BEEG problem in Missouri is it's the only state in the country without a central pharmacy so I can't tell if the patient is getting controlled substances elsewhere.

Why Wellbutrin and not Strattera? It makes sense for several reasons, but I haven't run into it being prescribed for patients. Maybe because my ADHD patients are all kids? I don't get any real ADHD adults in my practice.

 

[Shikima]

Why Wellbutrin and not Strattera? It makes sense for several reasons, but I haven't run into it being prescribed for patients. Maybe because my ADHD patients are all kids? I don't get any real ADHD adults in my practice.

More the willingness to look at alternative options rather than jumping straight to Adderall "because I took my friend's and it worked!"

 

[MacDonaldTriad]

Alliteration may suggest that private practice and prostitution are closely related, but that still remains an individual choice. If I’m wrong to criticize psychiatrists who treat adult ADHD, how do you explain the observation that this is the only psychiatric illness that spreads among college students like an epidemic? (With the possible exception of Koro). Federal, State, County, and academic jobs don’t pay very well, but they have a lot of other benefits none of which you will ever get me to apologize for or fell guilty about. So there.

 

[sunlioness]

A BEEG problem in Missouri is it's the only state in the country without a central pharmacy so I can't tell if the patient is getting controlled substances elsewhere.

Yeah, PA doesn't have one either. I feel blind.



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[whopper]

You might be right Sunlioness but I've seen lectures stating Missouri is THE ONLY STATE. Again I'm not in PA.

Personally I think it's stupid not to have a central pharmacy. I've had so many people show up to the ER stating they want Xanax. I wouldn't give it to them anyway but many of them, when I checked, were getting it from multiple doctors up the wazoo.

 

[MacDonaldTriad]

ER patient: “I want Xanax”.

ER doc: “Of course you do, but it would be inappropriate for me to give it to you in the context of an ER visit. Now how can I help you, preferably with something that is a first line treatment for something?”

 

[sunlioness]

You might be right Sunlioness but I've seen lectures stating Missouri is THE ONLY STATE. Again I'm not in PA.

Personally I think it's stupid not to have a central pharmacy. I've had so many people show up to the ER stating they want Xanax. I wouldn't give it to them anyway but many of them, when I checked, were getting it from multiple doctors up the wazoo.

Dr Google seems to indicate that Missouri is alone in saying, "We don't want this! Not gonna do it! Nuh uh."

PA, on the other hand, is more along the lines of, "What a fabulous idea! We're totally working on it. Please bear with us. It'll be a Thing. We promise." But . . .. They were saying that when I was a resident. I spent four years in IL in the interim (I now send ILPMP love letters), come back, and they're still singing the same song. The articles I found say, "48 other states have this thing. We almost have this thing. We want the Thing." One said we would have the Thing by June 2015. I don't think we have the Thing.


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[AcronymAllergy]

ADHD easy patients? IMHO yes and no. If the patient's honest and really has ADHD yes. Where I used to practice in Ohio I had strong reason to believe I was approached by a lot of bull$hitters.

Where I'm at in St. Louis so far none of the ADHD people I've had (and I've only been doing private practice about 5 weeks) seems to have been faking. How can I tell? Virtually every patient when asked to try Wellbutrin first has been open to it.

A BEEG problem in Missouri is it's the only state in the country without a central pharmacy so I can't tell if the patient is getting controlled substances elsewhere.

I only work on the assessment side of things, but I would agree. Evaluating ADHD in adults is probably one of the more frustrating things I do, and this is an area in which I did my dissertation.

As has been mentioned, the difficulty is confounded by the fact that "attention problems" is about as specific as "memory problems" in my practice (and much more frequently reported), the potential for external gain (i.e., stimulant medication) is inherent in every case, comorbidity of multiple conditions causing similar symptoms (in addition to h/o substance misuse) is high, I work with a relatively medically and psychologically complex population to begin with, access to childhood records and/or collateral report is limited at absolute best, and even results on objective cognitive measures aren't always particularly conclusive (or necessary for diagnosis).

There are also the problems associated with a patient having been previously given the diagnosis by some provider somewhere (usually after a brief interview and/or self-report screener), and so they've already bought into it whole-heartedly.

I'm not saying this particular physician is doing so, but if someone were diagnosing and subsequently treating based on a 15- or 20-minute interview and having the patient fill out a questionnaire or two, I could see that resulting in a very large outpatient pool. I don't know the base rates off-hand of individual ADHD symptoms in the general population, but I know they're pretty freakin' high.

 

[Shikima]

ER patient: “I want Xanax”.

ER doc: “Of course you do, but it would be inappropriate for me to give it to you in the context of an ER visit. Now how can I help you, preferably with something that is a first line treatment for something?”

I'd be amazed to know this is being said vs being given said drug or an injectable of Ativan and a psych consult isn't generated.

 

[smalltownpsych]

More the willingness to look at alternative options rather than jumping straight to Adderall "because I took my friend's and it worked!"

I knew that was what he was referring to in his post, but I was seriously interested in whether or not bupropion would be indicated for ADHD. My quick glance at the research is mixed on that point.

 

[Shikima]

I knew that was what he was referring to in his post, but I was seriously interested in whether or not bupropion would be indicated for ADHD. My quick glance at the research is mixed on that point.

Technically, it's the same brain chemicals being enhanced upon. Just wouldn't be through the RAS where amphetamines typically work.

 

[PikminOC]

There is a pediatrician in my area who is doing the same thing the OP is talking about.

 

[WisNeuro]

Alliteration may suggest that private practice and prostitution are closely related, but that still remains an individual choice. If I’m wrong to criticize psychiatrists who treat adult ADHD, how do you explain the observation that this is the only psychiatric illness that spreads among college students like an epidemic? (With the possible exception of Koro). Federal, State, County, and academic jobs don’t pay very well, but they have a lot of other benefits none of which you will ever get me to apologize for or fell guilty about. So there.

I always thought education was technically a protective factor in koro? Unless, of course, it's etiology is the fox spirit. That sucker is tenacious.

 

[Therapist4Chnge]

It still amazes me how ADHD prevalence rates could be so wrong in middle and upper-middle class towns….it's an epidemic!! Thankfully there are practices like the OP mentioned who have decided to step in and answer the need of all of those "outside of the numbers" kids. Not only do they have ADHD at a much higher rate than is seen elsewhere, but it tends to be very severe and require much higher dosing of stimulants to treat effectively. Even better, there are practices that cater to "adult onset" ADHD, which seems to be coming into its own as a current health challenge to white collar jobs everywhere. They too seem to be particularly in need of higher amounts of stimulants to function. /sarcasm

 

[MacDonaldTriad]

I always thought education was technically a protective factor in koro? Unless, of course, it's etiology is the fox spirit. That sucker is tenacious.

It is impressive how much education can be trumped by culture. I once had a Hatian masters level RN who told me that she was possessed by demons and that they were making her crazy. She was the definition of bouffée délirante. I asked her if she truly believed this given her western medical education and she said “of course, I’m Hatian”.

 

[Shikima]

https://www.fatherly.com/summary-a-...l&utm_source=facebook.com&utm_campaign=buffer

 

[PikminOC]

Let them deal with the PA's. I did a PA on generic Adderall. yesterday.

 

[Shikima]

Let them deal with the PA's. I did a PA on generic Adderall. yesterday.

My MA told me, "I'm so over doing Prior Auths!" She then put the phone down and picked up a People magazine and started to thumb through it.

 

[whopper]

The problem with ADHD is that it does exist, stimulants are the preferred treatment but that ADHD sx are very subjective-if using the DSM IV or V criteria pretty much everyone has it. Stimulants are abusable, have a street value, and if someone takes a stimulant even if they don't have ADHD they will be more focused. Hence the "I took the medication and felt more focused" doesn't mean the person has ADHD.

Add to the confusion the presenting sx is often times anxiety, "racing thoughts", and poor sleep leading this to be misdiagnosed.

Some tricks I've developed to help distinguish if it's ADHD vs other disorders.
1-What age did it start? IF it started very young e.g. age 5 it's likely not bipolar disorder or an anxiety disorder.
2-Clarify that when psychiatrists say "racing thoughts" we usually are really meaning thoughts that go very fast while in ADHD the person can't focus on their thoughts. There's a difference.
3-Does coffee calm the person down or make anxiety worse?
4-Trial one time low dosage of a stimulant. If a stimulant calms the person down they likely have ADHD for real.
5-Review academic records. That said I've seen some people with ADHD do very well in school but they had to work much harder than their colleagues or when they entered a very demanding academic field such as medicine or law their own techniques with dealing with their own ADHD that were once successful are no longer enough for graduate school (or college).

 

[AcronymAllergy]

The problem with ADHD is that it does exist, stimulants are the preferred treatment but that ADHD sx are very subjective-if using the DSM IV or V criteria pretty much everyone has it. Stimulants are abusable, have a street value, and if someone takes a stimulant even if they don't have ADHD they will be more focused. Hence the "I took the medication and felt more focused" doesn't mean the person has ADHD.

Add to the confusion the presenting sx is often times anxiety, "racing thoughts", and poor sleep leading this to be misdiagnosed.

Some tricks I've developed to help distinguish if it's ADHD vs other disorders.
1-What age did it start? IF it started very young e.g. age 5 it's likely not bipolar disorder or an anxiety disorder.
2-Clarify that when psychiatrists say "racing thoughts" we usually are really meaning thoughts that go very fast while in ADHD the person can't focus on their thoughts. There's a difference.
3-Does coffee calm the person down or make anxiety worse?
4-Trial one time low dosage of a stimulant. If a stimulant calms the person down they likely have ADHD for real.
5-Review academic records. That said I've seen some people with ADHD do very well in school but they had to work much harder than their colleagues or when they entered a very demanding academic field such as medicine or law their own techniques with dealing with their own ADHD that were once successful are no longer enough for graduate school (or college).

Excellent suggestions. To tack on a bit--

• I almost never have access to academic or even work records, but will query for signs of objective impairment and/or disparity (e.g., between intellectual functioning and academic performance/occupational attainment); even if symptoms were present, if they didn't cause impairment, it may not be ADHD
• Really attempt to dig into course; did symptoms remit in HS/college (e.g., as evidenced by grades), and then get worse again in adulthood? Could be persisting subclinical symptoms (present most folks with childhood ADHD) exacerbated by emotional distress/other factors
• Relationships with peers growing up (e.g., did they have lots of friends/make friends easily or tend to annoy other kids?); h/o immaturity and/or poor decision-making
• Comments made by teachers to students/parents
• Childhood h/o abuse? (could explain poor school performance, acting out behaviors, etc.)

All of these things obviously could be due to factors outside ADHD, so it really ends up being a diagnosis of exclusion. Symptom onset/course/duration is probably the most helpful piece of information to have, and the most difficult to objectively obtain.

 

[DD214_DOC]

Don't focus too much on hyperactive/impulsive symptoms and related dysfunction when getting childhood history, otherwise you may miss the predominantly inattentive types.

I ask for specific examples related to inattention and distractibility. Also, don't forget problems with executive functions and emotion regulation. These aren't separate diagnostic criteria but you should really see a combination of inattention and EF problems in the ADHD-I types.

Also, Wellbutrin is third line for ADHD so it really should never be your first choice unless you have a good reason. An aversion to giving stimulants to adults isn't a good reason. If that's the case, do your patients a favor and send them somewhere else for treatment.

Strattera is garbage. I don't use it because it never works.

It's not hard to figure out if a patient is abusing or diverting stimulants. Really, they're not that scary people.

 

[Therapist4Chnge]

The last handful of posts are spot on. I'd add that exec dysfunction needs to be eval'd bc this is where an adult w ADHD will often struggle. They may have learned strategies to cope, but they are often ineffective for higher level tasks.

(Typing on phone, so I'll add to this tomorrow when I'm back in my office)