ADHD drugs face new rules on college campuses

[PHD12]

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Some colleges are requiring neuropsychological testing before prescribing ADHD pills. Students receiving prescriptions are also required to attend 50-minute therapy sessions.

http://www.nytimes.com/2013/05/01/us/colleges-tackle-illicit-use-of-adhd-pills.html?pagewanted=1

"Fresno State no longer makes diagnoses, largely because of the substantial time required “to do it right,” said Catherine Felix, its director of health and psychological services. Many universities, including North Carolina State, Georgia Tech and Penn State, also said they could no longer handle the volume of requests. "

 

[psychRA]

Personally, I find this very troublesome.

First of all, out of pocket neuropsych testing is not cheap. If university health centers now require testing but won't provide it in-house, are they going to cover the costs testing in the community? If not, lower income students with ADHD are now at a tremendous disadvantage compared to students who can afford a $1200-2000 private practice assessment.

Second, are schools going to require recent testing? If you have a student who was tested at age 6 and has been on stimulants ever since, requiring an updated battery seems like a waste of time and resources. Hell, even if this student was diagnosed by an interview with regular old family doctor, if they've been taking meds and benefiting from them for years, is there really a clinical justification for doing a neuropsych battery at this point?

Stimulant medications are highly regulated, as they should be: Paper prescriptions only, and no refills, so at the very least, you have to go to a doctor's office once a month to pick up the script. If you attend college out of town our out of state, this means that your family doctor who's been prescribing your ritalin since you were ten years old can't help you. Your school's health center may be the ONLY way to get your meds prescribed. Sure, you could find a psychiatrist in private practice who is willing to prescribe based on the standard ADHD questionnaires, but that's generally going to be much more expensive than being seen at the university health center. Again, it puts an unfair burden on students with ADHD who can't afford private neuropsych testing.

And finally...monthly therapy sessions? For what, exactly? As far as I know, the evidence for psychological treatment for ADHD is mixed at best, and they've been tested mainly in children and adolescents, not early adults. If someone really has no mental health issues other than ADHD, requiring them to go to monthly therapy seems like a poor use of resources.

I get that schools don't want students to abuse stimulant medication, but this seems to place an unfair burden on the students who legitimately need it.

 

[AcronymAllergy]

Personally, I find this very troublesome.

First of all, out of pocket neuropsych testing is not cheap. If university health centers now require testing but won't provide it in-house, are they going to cover the costs testing in the community? If not, lower income students with ADHD are now at a tremendous disadvantage compared to students who can afford a $1200-2000 private practice assessment.

Second, are schools going to require recent testing? If you have a student who was tested at age 6 and has been on stimulants ever since, requiring an updated battery seems like a waste of time and resources. Hell, even if this student was diagnosed by an interview with regular old family doctor, if they've been taking meds and benefiting from them for years, is there really a clinical justification for doing a neuropsych battery at this point?

Stimulant medications are highly regulated, as they should be: Paper prescriptions only, and no refills, so at the very least, you have to go to a doctor's office once a month to pick up the script. If you attend college out of town our out of state, this means that your family doctor who's been prescribing your ritalin since you were ten years old can't help you. Your school's health center may be the ONLY way to get your meds prescribed. Sure, you could find a psychiatrist in private practice who is willing to prescribe based on the standard ADHD questionnaires, but that's generally going to be much more expensive than being seen at the university health center. Again, it puts an unfair burden on students with ADHD who can't afford private neuropsych testing.

And finally...monthly therapy sessions? For what, exactly? As far as I know, the evidence for psychological treatment for ADHD is mixed at best, and they've been tested mainly in children and adolescents, not early adults. If someone really has no mental health issues other than ADHD, requiring them to go to monthly therapy seems like a poor use of resources.

I get that schools don't want students to abuse stimulant medication, but this seems to place an unfair burden on the students who legitimately need it.

Regarding the bolded portion, I would definitely say yes. While a number of individuals continue to experience some degree of symptoms into adulthood, 1) the symptoms themselves aren't necessarily uncommon, and 2) most individuals still tend to "outgrow" the disorder in adulthood. Thus, if the last assessment was done 12+ years ago, a new one could certainly be warranted.

I agree regarding the pricing portion, though. And the jury's still largely out on the value of neuropsychological testing in ADHD assessment. It can be useful if there are multiple rule-outs involved, but for "just" ADHD, interviews and behavior rating scales would be just as useful and much cheaper. If learning disorders are also a concern, then request a psychoed, but even that would likely be cheaper than a neuropsych eval.

My best guess is the schools want some sort of quantifiable deficit (e.g., below-expected processing speed) in order to justify the use of medication.

The university I attended required extensive testing/documentation for accommodations, but our clinic also provided acceptable testing at a hugely discounted rate.

 

[cara susanna]

The university I attended required extensive testing/documentation for accommodations, but our clinic also provided acceptable testing at a hugely discounted rate.

Ditto for my university. What we usually find is that the students have concentration difficulties, but they're sub-clinical.

 

[Ollie123]

I do testing for it right now through our clinic and I'd hope most schools requiring it are offering this as an option...its really an incredibly steep discount at most school clinics and my school even has a grant where disability evaluations (ADHD or otherwise) are provided for free to students who can't afford it. I'm somewhat in agreement RE: therapy since as you said - the literature supporting this is not great in adults (though I'd actually argue its quite strong in children if you look at truly intensive behavioral treatments).

That said, something needs to be done. I'd go so far as to guess the "majority" of students on stimulant meds these days likely don't have ADHD, at least at my campus. Unfortunately it has spiraled out of control and PCPs seem to hand them out like halloween candy to anyone who complains of troubles concentrating so as far as I'm concerned whether someone has a history of being prescribed stimulants tells me virtually nothing about their likelihood of having ADHD. Some had it as children but have "outgrown" it, some knowingly sought it out as a "study aid", some have concentration difficulties better accounted for by a comorbid condition (e.g. depression), but I've encountered relatively few with actual ADHD. I think a more middle-of-the-road approach would be better than what is implemented, but the status quo (pills for everyone, no questions asked) should not be maintained.

 

[Buzzwordsoldier]

That said, something needs to be done. I'd go so far as to guess the "majority" of students on stimulant meds these days likely don't have ADHD, at least at my campus. Unfortunately it has spiraled out of control and PCPs seem to hand them out like halloween candy to anyone who complains of troubles concentrating so as far as I'm concerned whether someone has a history of being prescribed stimulants tells me virtually nothing about their likelihood of having ADHD.

Not to be funny, but...

the fantasy of control legitimizes the pez candy dispensing, which spurs the spiraling. Now...if someone could only prove that without feeding the impulse to control a-la experimental design....

 

[coldsweat]

I used to work at a clinic that primarily performed assessments for ADHD in college students. The health insurance provided by the university covered the full cost of the evaluation. For those who didn't have the insurance, the evaluation was costly ($500), although compared to other clinics this rate is a solid discount.

 

[ela]

I'm curious what people who work / prac / intern in UCC's use for their ADHD battery. I've been at a number of sites, all of which approach a bit differently. Somewhat typical;

Structured interview (ACDS)
CAARS self + observer
CPT (Conners, TOVA).

What about other folks? I'd like to add some sort of SVT...something quick. Feedback appreciated.

 

[ellenew]

I'm curious what people who work / prac / intern in UCC's use for their ADHD battery. I've been at a number of sites, all of which approach a bit differently. Somewhat typical;

Structured interview (ACDS)
CAARS self + observer
CPT (Conners, TOVA).

What about other folks? I'd like to add some sort of SVT...something quick. Feedback appreciated.

I don't work at a UCC, but the clinic where my program provides services at the university does all of the testing. We are required to administer achievement and intelligence tests in addition to self reports.

 

[G Costanza]

Ditto for my university. What we usually find is that the students have concentration difficulties, but they're sub-clinical.

Ditto for mine as well. I think it's very important that students with limited resources not be excluded from medications. That being said, this is the only of four universities I've worked at requiring testing and also the lowest abuse of stimulants I've seen in my practice. Anecdotal caveat.

 

[RejectClinical]

And the jury's still largely out on the value of neuropsychological testing in ADHD assessment.

Exactly.....people keep perpetuating the idea that neuropsych testing is the gold standard for ADHD diagnosis. *sigh*

https://www.ncbi.nlm.nih.gov/pubmed/24639037

 

[Istilldontknow]

I understand what they're trying to do, but this is just going to harm students who actually have a disorder and utilize stimulants appropriately. If a student is diagnosed with ADHD and are required to have neurological testing, won't they need to stop taking their medications in order for testing to be accurate? This can be harmful in multiple ways. In addition, stimulants are prescribed for more than just ADHD. Regardless of personal opinions, they can be used to treat MDD, chronic fatigue, etc. So a student prescribed these medications for other disorders are forced to go off of them?

This brings up so many other issues related to mental (and physical) health care in the U.S. and is one I have personal experience with. I've had the same tx team for over a decade and have tx resistant double depression. I've tried every type of antidepressants, a million different doses and interactions, and nothing makes even the slightest difference. Last year, my psych decided to try adderall, and it has been the only relief I've felt since I was a child. I moved out of state for grad school shortly after beginning these meds, and it is impossible for me to get my Rx here-even though I have had the same doctor for over a decade, tons of testing, and a huge history of trying other treatments. So every month, my mom has to pick up my rx from my psych, fill it in my home state, and illegally mail it to me. Whatever anyone thinks about the uses of stimulants, it has been the only thing thus far to help me, and the hoops I (and my mom) have to go through every month to have it is ridiculous.

-Sorry, rant over.

 

[smalltownpsych]

Messy stuff when the drug that provides the treatment also hits the reward centers of the brain. Gets even messier when you mix in large systems with power and responsibility for student welfare such as a university and mix that up with healthcare treatments. I always love it when I have the patient in my room and we are at the nexus of these types of messy situations and I am supposed to "do something" and there is really no good answer. "Yes, stimulants could help you, but they also might get people addicted and destroy their lives and I have no reliable way of predicting any of this, but everyone thinks I should because I am the expert so..."

 

[WisNeuro]

Testing is pretty much only useful to find the malingerers and to rule out other conditions. A CPT or TOVA in isolation are useless tests.

 

[psych.meout]

Testing is pretty much only useful to find the malingerers and to rule out other conditions. A CPT or TOVA in isolation are useless tests.

Yea, aren't they really only valuable for PVTs, SVTs, and differential diagnosis when there is potential for messy comorbidities?

It seems like getting high school and college transcripts would be a good way to inform on diagnosis and treatment plans for ADHD in college populations. E.g. looking into malingering and secondary gain issues for a pre-med student suddenly reporting ADHD symptoms leading up to taking the MCAT so they can get stimulant meds and accommodations even though they have a history of being a stellar student prior to seeking assistance for ADHD.

 

[WisNeuro]

Yea, aren't they really only valuable for PVTs, SVTs, and differential diagnosis when there is potential for messy comorbidities?

Yeah, our clinic did accommodations testing for the University. The rate of invalid performers was about 40%. Another portion were just low average intelligence students, and another portion just had untreated anxiety/depression. Lots of people think they have ADHD because it would give them an acceptable reason for not doing well, when they actually just have other things going on.

 

[erg923]

I understand what they're trying to do, but this is just going to harm students who actually have a disorder and utilize stimulants appropriately. If a student is diagnosed with ADHD and are required to have neurological testing, won't they need to stop taking their medications in order for testing to be accurate? This can be harmful in multiple ways. In addition, stimulants are prescribed for more than just ADHD. Regardless of personal opinions, they can be used to treat MDD, chronic fatigue, etc. So a student prescribed these medications for other disorders are forced to go off of them?

This brings up so many other issues related to mental (and physical) health care in the U.S. and is one I have personal experience with. I've had the same tx team for over a decade and have tx resistant double depression. I've tried every type of antidepressants, a million different doses and interactions, and nothing makes even the slightest difference. Last year, my psych decided to try adderall, and it has been the only relief I've felt since I was a child. I moved out of state for grad school shortly after beginning these meds, and it is impossible for me to get my Rx here-even though I have had the same doctor for over a decade, tons of testing, and a huge history of trying other treatments. So every month, my mom has to pick up my rx from my psych, fill it in my home state, and illegally mail it to me. Whatever anyone thinks about the uses of stimulants, it has been the only thing thus far to help me, and the hoops I (and my mom) have to go through every month to have it is ridiculous.

-Sorry, rant over.

"Double depression?"

 

[WisNeuro]

"Double depression?"

Dysthymia with an overlay of episodic major depressive episodes.

 

[erg923]

Dysthymia with an overlay of episodic major depressive episodes.

So...MDEs that never full recover/remit?

I've never heard that term.

 

[WisNeuro]

So...MDEs that never full recover/remit?

I've never heard that term.

Well, they're not MDE's when some of the symptoms and severity die down, hence the dysthymia. I'm surprised you haven't heard this. It's been a concept for quite some time and is not controversial.

 

[smalltownpsych]

Well, they're not MDE's when some of the symptoms and severity die down, hence the dysthymia. I'm surprised you haven't heard this. It's been a concept for quite some time and is not controversial.

That's kind of funny because my first memory of "double depression" was framed in the context of some disagreement about the construct of dysthymia itself and some discussion about depressive personality disorder. Not saying it should be controversial or is even a significant point of contention, but it is almost hard to think of anything in the field of psychology that doesn't have some controversy attached to it. 😀

 

[Fan_of_Meehl]

Personally, I find this very troublesome.

First of all, out of pocket neuropsych testing is not cheap. If university health centers now require testing but won't provide it in-house, are they going to cover the costs testing in the community? If not, lower income students with ADHD are now at a tremendous disadvantage compared to students who can afford a $1200-2000 private practice assessment.

Second, are schools going to require recent testing? If you have a student who was tested at age 6 and has been on stimulants ever since, requiring an updated battery seems like a waste of time and resources. Hell, even if this student was diagnosed by an interview with regular old family doctor, if they've been taking meds and benefiting from them for years, is there really a clinical justification for doing a neuropsych battery at this point?

Stimulant medications are highly regulated, as they should be: Paper prescriptions only, and no refills, so at the very least, you have to go to a doctor's office once a month to pick up the script. If you attend college out of town our out of state, this means that your family doctor who's been prescribing your ritalin since you were ten years old can't help you. Your school's health center may be the ONLY way to get your meds prescribed. Sure, you could find a psychiatrist in private practice who is willing to prescribe based on the standard ADHD questionnaires, but that's generally going to be much more expensive than being seen at the university health center. Again, it puts an unfair burden on students with ADHD who can't afford private neuropsych testing.

And finally...monthly therapy sessions? For what, exactly? As far as I know, the evidence for psychological treatment for ADHD is mixed at best, and they've been tested mainly in children and adolescents, not early adults. If someone really has no mental health issues other than ADHD, requiring them to go to monthly therapy seems like a poor use of resources.

I get that schools don't want students to abuse stimulant medication, but this seems to place an unfair burden on the students who legitimately need it.

This suggestion is kind of off the cuff--so bear with me, but I wonder if it doesn't make sense for universities to have 'in-house' psychology/neuropsychology staff to handle these kinds of scenarios (and that the students could access free of charge or at a reduced rate / steep sliding scale)?

I mean, school psychologists (K-12 levels) are nearly ubiquitous nowadays to deal with these sorts of questions. I wouldn't imagine that it would be infeasible for a university budget to cover the costs of a couple of psychologists and/or masters-level trainees to handle the workload. Most universities would have psychology graduate programs already in place, it would just be a matter of sending consults through that service.

Edit: from reviewing the above posts, it looks like these kinds of services are available at a lot of institutions (deep-discounted services from in-house psychology/education graduate programs). For those schools that don't, could them requiring expensive testing be conceptualized as an undue burden placed on them due to their disability (presumed, I suppose) and open them to lawsuits? They may just want to provide those services anyway to protect against such legal exposure and, perhaps indirectly, to strive to maintain the integrity of their academic programs. It occurs to me that the more subtle the 'cognitive disability/dysfunction' is that supposedly underlies lack of academic performance at the collegiate level, the more likely it becomes that we start labeling garden-variety 'lack of ability' as 'medical disability.' I don't think that the implicit assumption that everyone is capable of passing collegiate-level coursework (in every field of study) is necessarily sound (and was not historically assumed). There are so many factors that could contribute to impaired academic performance, any evaluative process that would seek to reliably/validly isolate and enumerate the contributors would necessarily have to be extremely exhaustive and multi-dimensional (and expensive and time-consuming).

 

[calimich]

The UCC I intern'd/postdoc'd at had an in-house clinic with tests predominately administered by trainees:

BrownADD, WAIS, CAARS self + observer, CPT, WCST, CVLT, Delis-Kaplan.

Interestingly, University medical providers stopped prescribing stimulants a few years back. So while we could diagnose a student, they had to see an off-campus provider to get meds. The U thought this reduced abuse, at least their liability anyway.

 

[AcronymAllergy]

The in-house psych clinic at my grad program also primarily conducted psychoeds. They were in very high demand because the price was ridiculously low compared to the community.

 

[Istilldontknow]

Looks like everyone else already explained. But yea, dysthymia with recurrent, severe MDD episodes.

 

[DynamicDidactic]

what a resurrection of an old thread.

Has there actually been a change in typical university policy since this almost 4 year old article? I haven't seen it.

I am in support of a system of assessment that includes more a 15 minute interview and a rating scale with a likely script afterward. From anecdotal conversation with college students this is a typical method of diagnosis. In grad school, I probably did more ADHD evals than anything else but I am no expert. It seems to me that being able to provide some sort of evidence aside from interviews is useful for assessment.

Again from my early anecdotal experience, anxiety (social, panic, sub-clinical) seems to be a bigger problem than attentional difficulties.

 

[psych.meout]

what a resurrection of an old thread.

Has there actually been a change in typical university policy since this almost 4 year old article? I haven't seen it.

I am in support of a system of assessment that includes more a 15 minute interview and a rating scale with a likely script afterward. From anecdotal conversation with college students this is a typical method of diagnosis. In grad school, I probably did more ADHD evals than anything else but I am no expert. It seems to me that being able to provide some sort of evidence aside from interviews is useful for assessment.

Again from my early anecdotal experience, anxiety (social, panic, sub-clinical) seems to be a bigger problem than attentional difficulties.

When I was at clinical program interviews recently, this seemed to be the pattern for their in-house clinics as well.

One even said that they experienced an influx of undergrad inquiries (they served both the university population and the local community) around mid-terms and finals, both about anxiety/stress management and possible ADHD. They were similar to one of the programs in the OP, as they required neuropsych evals for accommodations and scripts.