ADHD testing when Pt has cannabis use disorder?

[Childdoconeday]

Adolescent pt and parent came in to inquire about ADHD testing for adolescent pt in order to get him accommodations and support for school. Pt has longstanding history of difficulties with inattention since kindergarten. He attends school in area that is known for horrendous schools and moving students on to the next grade even if they are struggling significantly. He now attends a new school and mother wants to get him support. Pt has significant behavioral difficulties and also smokes marijuana every night. He does not plan to stop and mother smokes as well and is supportive of him doing so, despite being aware of the impact of marijuana use.

Can I ethically test him? Provide rating scales to his teachers (he and mother state that he is sober during the day)?

Thank you for your time.

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[PsyDr]

I think you’ll find the DSM’s requirement to assure that the symptoms are not due to a substance, helpful.

 

[psych.meout]

Sounds like it's time for some psychoeducation about how cannabis works.

Also, does the parent's "support" include supplying the patient with the cannabis? If so, isn't there an ethical issue if the patient is a minor?

 

[Childdoconeday]

Sounds like it's time for some psychoeducation about how cannabis works.

Also, does the parent's "support" include supplying the patient with the cannabis? If so, isn't there an ethical issue if the patient is a minor?

Yeah I gave a lot of psycho-ed but mom uses it and supports him by basically allowing him to do it, she is not providing it to him.

 

[bcliff]

What is the value of a formal assessment? Sounds like psychotherapy is warranted. CBT for ADHD focuses on building executive functioning/compensatory skills and can be paired nicely with values-based interventions, like ACT and/or behavioral activation. Regular therapy appointments will also allow for psychoeducation on the impact of substance use during adolescence to be reinforced to both patient and parent and for some MI re: substance use to be implemented as well.

I’m struggling to understand the incremental validity of a Conners, BASC, CPT, WISC, etc. in this situation. If parent insists, then I would be transparent about the noise introduced by substance use and would recommend that we not test until patient has abstained from substances for a period of time supported by empirical literature — Depending on intensity, cannabis use might have already had an irreversible impact on patients neuro development, in which case a neurodevelopmental dx may be warranted.

 

[MAClinician]

You may want to consult with someone who is familiar with the laws in the state you work in with regard to marijuana. In some states, even if the parent/guardian/caregiver is not directly supplying the drug but is allowing it to to be used by an underage person, it could be considered child neglect or contributing to the delinquency of a minor. And your role may be considered a mandatory reporter. This can still occur even in states where recreational marijuana use is permitted by law, as those laws typically apply to 21+. Something else to consider , outside of whether you test or not.

 

[bcliff]

Agree that parent “support” of underage marijuana use sounds neglectful to me. I don’t work much with kids, so I’m not sure how the law looks at situations like this. Consult with trusted colleagues, consult/defer to your supervisor, etc.

 

[Childdoconeday]

Agree that parent “support” of underage marijuana use sounds neglectful to me. I don’t work much with kids, so I’m not sure how the law looks at situations like this. Consult with trusted colleagues, consult/defer to your supervisor, etc.

Wow thanks everyone. I honestly hadn’t thought about it that way and will immediately consult with my manager tomorrow. Thank you all for your responses

 

[erg923]

Adolescent pt and parent came in to inquire about ADHD testing for adolescent pt in order to get him accommodations and support for school.

That's the schools job/responsibility. Its law. Your tax dollars pay for it, and it would be fraudulent to try to bill insurance or medicaid for ttis type of evaluation.

Also:

Neuropsychological Testing for ADHD Diagnosis

Hi all, Does anyone have any specific articles or references supporting that neuropsych testing is not necessary for an ADHD diagnosis? If so, could you please link or share them with me? Thanks!

forums.studentdoctor.net

Also:

 

[cara susanna]

Had a case like this on internship (found out during the clinical interview portion that dude was smoking a ton of weed) and we ended up not testing on my supervisor's recommendation.

 

[WisNeuro]

I have refused testing when I would not be able to discriminate effects of a substance vs an underlying neurological issue. Similar instance recently with a gentleman who smoked large amounts of MJ daily and was having memory and attention problems. Would not commit to cessation for purposes of testing, so I declined the referral. I would have done the same in the OP's case. Too many people on my waiting list to waste an eval spot on such nonsense.

 

[Childdoconeday]

Thank you all for your feedback and responses. I can’t even tell you how much I appreciate you all and this resource! I ended up sharing my concerns with mom and told her that testing would need to be put on hike for now. She cursed at me and told me that she’s going to go to another provider and will lie about his substance use next time, so that she can get the diagnosis. Oh well. At least I can sleep well knowing that I did the right thing. I did consult with my supervisor and we are going to err on the side of reporting, as mom is refusing to seek substance use treatment for him and is allowing him to smoke daily in the house.

I have refused testing when I would not be able to discriminate effects of a substance vs an underlying neurological issue. Similar instance recently with a gentleman who smoked large amounts of MJ daily and was having memory and attention problems. Would not commit to cessation for purposes of testing, so I declined the referral. I would have done the same in the OP's case. Too many people on my waiting list to waste an eval spot on such nonsense.

 

[Childdoconeday]

Oops meant to write testing would need to be put on hold

Thank you all for your feedback and responses. I can’t even tell you how much I appreciate you all and this resource! I ended up sharing my concerns with mom and told her that testing would need to be put on hike for now. She cursed at me and told me that she’s going to go to another provider and will lie about his substance use next time, so that she can get the diagnosis. Oh well. At least I can sleep well knowing that I did the right thing. I did consult with my supervisor and we are going to err on the side of reporting, as mom is refusing to seek substance use treatment for him and is allowing him to smoke daily in the house.

 

[cara susanna]

Thank you all for your feedback and responses. I can’t even tell you how much I appreciate you all and this resource! I ended up sharing my concerns with mom and told her that testing would need to be put on hike for now. She cursed at me and told me that she’s going to go to another provider and will lie about his substance use next time, so that she can get the diagnosis. Oh well. At least I can sleep well knowing that I did the right thing. I did consult with my supervisor and we are going to err on the side of reporting, as mom is refusing to seek substance use treatment for him and is allowing him to smoke daily in the house.

Sorry you had to deal with an angry mom (that's never fun), but it sounds like you did the right thing.

 

[Fan_of_Meehl]

Thank you all for your feedback and responses. I can’t even tell you how much I appreciate you all and this resource! I ended up sharing my concerns with mom and told her that testing would need to be put on hike for now. She cursed at me and told me that she’s going to go to another provider and will lie about his substance use next time, so that she can get the diagnosis. Oh well. At least I can sleep well knowing that I did the right thing. I did consult with my supervisor and we are going to err on the side of reporting, as mom is refusing to seek substance use treatment for him and is allowing him to smoke daily in the house.

"so that she can get the diagnosis"

Yeah, there is a disturbingly large (and growing) segment of the mental health population who conceptualize the visit to a provider's office to 'pick up' a particular diagnosis as somehow akin to driving through the local fast food joint to 'pick up' their favorite burger.

No, this isn't Burger King and, no, you can't necessarily 'have it your way.'

Kudos for you for sticking to your ethical guns.

 

[AbnormalPsych]

Agree with everyone else. I have delayed testing before for similar reasons and for the most part, patients understand.

Curious if you all have rules of thumb or stricter criteria for periods of sobriety prior to testing. I have been in clinics with informal 30 days off MJ, ETOH, etc policies.

Edit: 30 days for heavy users/abusers.

 

[erg923]

I would say 3 months for long-term, heavy etoh users. At least a month for other stuff, including mj. Its really not that long to wait. Whether they are motivated and understand why its important is another issue.