ADHD testing?

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therow

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Currently, in my training at our psychology clinic, we offer ADHD testing and our typical batteries include: DKEFS, WAIS, CPT-3, BRIEFS/BROWN. I feel like these alone are not sufficient in formulating an ADHD diagnosis? I'm just curious about other test batteries that are included for an adhd diagnosis as ultimately this is a neurodevelopmental disorder. It also seems like the biggest thing is that people just report they have problems staying focused and concentrating but it's obviously difficult for anyone to stay focused for 8 hours consecutively at school.
 
therow said:
Currently, in my training at our psychology clinic, we offer ADHD testing and our typical batteries include: DKEFS, WAIS, CPT-3, BRIEFS/BROWN. I feel like these alone are not sufficient in formulating an ADHD diagnosis? I'm just curious about other test batteries that are included for an adhd diagnosis as ultimately this is a neurodevelopmental disorder. It also seems like the biggest thing is that people just report they have problems staying focused and concentrating but it's obviously difficult for anyone to stay focused for 8 hours consecutively at school.
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There are neither necessary at all, nor sufficient.
 
Bill Hader Popcorn GIF by Saturday Night Live
 
You don't need any of those. A good structured interview and collateral information to establish problems in two or more settings is all you need. Testing will mostly will rule out other causes in a differential. One should also rule out psychiatric and sleep disturbance as possible explanations for symptoms.
 
Sanman said:
You don't need any of those. A good structured interview and collateral information to establish problems in two or more settings is all you need. Testing will mostly will rule out other causes in a differential. One should also rule out psychiatric and sleep disturbance as possible explanations for symptoms.
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Can't it be argued that having those performance based measures can provide additional information/ evidence though?
 
therow said:
Can't it be argued that having those performance based measures can provide additional information/ evidence though?
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Evidence of what? ADHD? Can you show us in the literature where there is a cognitive testing profile of ADHD that has good sensitivity and specificity?

You might be interested in what Russell Barkley has to say about neuropsych testing for ADHD.
 
therow said:
Can't it be argued that having those performance based measures can provide additional information/ evidence though?
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Not in any incremental way above and beyond the clinical history that justifies the time and expense of those measures. And, many would argue that they will actually increase the chance of misdiagnosis in some contexts.
 
Every neuropsychologist I've worked with has said that you only need a good clinical interview and, ideally, collateral. I include a PAI or MMPI-2 just to look at response style, but even that isn't really necessary.
 
therow said:
Can't it be argued that having those performance based measures can provide additional information/ evidence though?
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You can argue anything you want. The question becomes evidence of what?

So let me answer a question with a question, you have someone that shows significant impairment on a CPT-3 for sustained attention and inattentiveness. On interview, you find out that they got 4 hrs of sleep the previous night. What you have evidence of exactly?

https://journals.sagepub.com/doi/full/10.1177/1087054719897811
 
If you mean an in-house university clinic, I'd assume the battery is aimed to meet the uni ability and access office reqs, in which case you're kind of beholden to what that office wants, if you want the reports to be useful. Or you could argue with them I guess.

Maybe designed to meet the MCAT/LSAT/GRE reqs. In that case it's probably insufficient, last I checked MCAT/LSAT/GRE also required a PVT as one difference between that battery and their reqs.
 
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therow said:
Can't it be argued that having those performance based measures can provide additional information/ evidence though?
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The problem is that ADHD is not just a deficit in executive functioning. It's a highly heterogenous condition that can include deficits in executive functioning. Also, people with ADHD (especially those with higher IQs) can rally for short periods of time to perform well on neurocognitive tasks, only to still be impaired in their everyday lives. This has been widely shown in the literature, including metas I've linked in other recent threads.
 
R. Matey said:
The problem is that ADHD is not just a deficit in executive functioning. It's a highly heterogenous condition that can include deficits in executive functioning. Also, people with ADHD (especially those with higher IQs) can rally for short periods of time to perform well on neurocognitive tasks, only to still be impaired in their everyday lives. This has been widely shown in the literature, including metas I've linked in other recent threads.
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We are seeing that a lot of people coming in with adhd referral questions are performing quite well on these tests (WAIS) despite complaints of this attention/focus in the interview
 
MCParent said:
If you mean an in-house university clinic, I'd assume the battery is aimed to meet the uni ability and access office reqs, in which case you're kind of beholden to what that office wants, if you want the reports to be useful. Or you could argue with them I guess.

Maybe designed to meet the MCAT/LSAT/GRE reqs. In that case it's probably insufficient, last I checked MCAT/LSAT/GRE also required a PVT as one difference between that battery and their reqs.
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yes youre right
 
therow said:
We are seeing that a lot of people coming in with adhd referral questions are performing quite well on these tests (WAIS) despite complaints of this attention/focus in the interview
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Which is the main issue with cognitive testing in ADHD: the tests are not especially sensitive or specific to the diagnosis, and there's no specific profile that's particularly unique to ADHD. Plenty of people with ADHD perform within normal limits on testing, and people without ADHD (but who may have other factors at play) can exhibit impairments on testing, with both situations potentially resulting in misdiagnosis.

For example, if a person meets all criteria for ADHD per clinical interview and behavioral rating scales, but does well on the WAIS and DKEFS, are you not going to diagnose ADHD? To not do so would generally be inconsistent with diagnostic criteria, unless you had some other rationale beyond them performing normally on cognitive testing.
 
AcronymAllergy said:
Which is the main issue with cognitive testing in ADHD: the tests are not especially sensitive or specific to the diagnosis, and there's no specific profile that's particularly unique to ADHD. Plenty of people with ADHD perform within normal limits on testing, and people without ADHD (but who may have other factors at play) can exhibit impairments on testing, with both situations potentially resulting in misdiagnosis.

For example, if a person meets all criteria for ADHD per clinical interview and behavioral rating scales, but does well on the WAIS and DKEFS, are you not going to diagnose ADHD? To not do so would generally be inconsistent with diagnostic criteria, unless you had some other rationale beyond them performing normally on cognitive testing.
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thanks for the insight, helpful as a student still learning
 
MCParent said:
My favorite phrase! Jk 🙂

Well then. Not the battery I’d use, anyone wanting accommodations on standardized testing in 2 years is going to need to get it again. And as other said, overkill for just a dx.
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in terms of potential batteries, would you just focused on an in-depth clinical interview? just a student trainee trying to learn!
 
therow said:
in terms of potential batteries, would you just focused on an in-depth clinical interview? just a student trainee trying to learn!
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For a university clinic? When I ran mine I talked with the access office about what they wanted and then looked at the mcat/lsat/gre provider documentation (it’s on their web sites) to make sure any positive testing would also work for that.
 
AcronymAllergy said:
Which is the main issue with cognitive testing in ADHD: the tests are not especially sensitive or specific to the diagnosis, and there's no specific profile that's particularly unique to ADHD. Plenty of people with ADHD perform within normal limits on testing, and people without ADHD (but who may have other factors at play) can exhibit impairments on testing, with both situations potentially resulting in misdiagnosis.

For example, if a person meets all criteria for ADHD per clinical interview and behavioral rating scales, but does well on the WAIS and DKEFS, are you not going to diagnose ADHD? To not do so would generally be inconsistent with diagnostic criteria, unless you had some other rationale beyond them performing normally on cognitive testing.
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whats not to say that someone couldnt just be faking what they're sharing on the clinical interview? like lets say they read the dsm-5 criteria beforehand
 
MCParent said:
For a university clinic? When I ran mine I talked with the access office about what they wanted and then looked at the mcat/lsat/gre provider documentation (it’s on their web sites) to make sure any positive testing would also work for that.
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This is what we did back in my grad school days as well.
 
therow said:
whats not to say that someone couldnt just be faking what they're sharing on the clinical interview? like lets say they read the dsm-5 criteria beforehand
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Nothing, and it's a real concern with ADHD evaluations. That said, the cognitive testing isn't going to help with it, for the reasons I mentioned above. Potential alternatives include using a structured clinical interview to try to gather more specific information that may not be as easily feigned, and including symptom validity tests in your evaluation (along with other questionnaires/checklists/measures). I suppose an advantage to cognitive testing would be inclusion of performance validity tests, although the main benefit, as MCParent has discussed, is that the cognitive testing is often necessary for formal accommodations (especially high-stakes, like standardized testing).
 
therow said:
whats not to say that someone couldnt just be faking what they're sharing on the clinical interview? like lets say they read the dsm-5 criteria beforehand
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That's true for any assessment for any diagnosis, though. I wish I knew why ADHD is treated soooo differently. I know it's because the meds can be abused, but isn't prescribing a separate consideration from actually rendering the diagnosis?
 
cara susanna said:
That's true for any assessment for any diagnosis, though. I wish I knew why ADHD is treated soooo differently. I know it's because the meds can be abused, but isn't prescribing a separate consideration from actually rendering the diagnosis?
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Right but the incentive for malingering on the part of the patient is usually negligible for treatments without addictive potential.
Nobody is coming in all hot and heavy faking their test results just to get their hands on some juicy Depakote or Paxil.
 
cara susanna said:
That's true for any assessment for any diagnosis, though. I wish I knew why ADHD is treated soooo differently. I know it's because the meds can be abused, but isn't prescribing a separate consideration from actually rendering the diagnosis?
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Like tr said, I think the reasons ADHD is treated differently are essentially that the incentives are stronger and the symptoms, in isolation, very common and somewhat nebulous. The medications have addictive potential, are helpful for just about anyone, and have risk for diversion; and even beyond medication, there are other incentives including academic and testing accommodations. I also think many MH providers are less comfortable/familiar with ADHD diagnosis than they are, say, anxiety. Although I know you know all this already.

But you make a good point--symptom fabrication/magnification is possible in any mental health exam. Which is why I'm a proponent of considering this point in all evaluations, not just those that are overtly forensic or high-stakes. Too often, clinicians seem to "pass the buck" when it comes to this (e.g., "it's not my job to try to determine if the patient's being truthful about their symptoms"), which is problematic given the iatrogenesis possible with misdiagnosis and/or misadministration of treatment.
 
tr said:
Right but the incentive for malingering on the part of the patient is usually negligible for treatments without addictive potential.
Nobody is coming in all hot and heavy faking their test results just to get their hands on some juicy Depakote or Paxil.
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Maybe, but we, as far as I know, don't have PVTs for anxiety disorders where some of the psychiatric treatments can also be habit forming.
 
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I differ: I think the testing is a decent approach to diagnosis.

Pretty much all DSM diagnoses can be accomplished by clinical interview. People can, and will, disguise important aspects of their lives for many reasons (e.g., malingering, embarrassment, avoiding emotional experiences, belief that something is irrelevant, etc.). Some people will have performance issues due to factors like: intelligence not commiserate with environmental demands, low conscientiousness, excessive home life demands, disinterest in subject areas secondary to personality structure, negative personality structures, lifestyle choices, medical status, secondary gain, etc.

As psychiatry has progressively narrowed their interventions to medication, such factors have become less interesting to all. If your interventions for Major Neurocognitve Disorder due to probable Alzheimer's is going to be limited to aricept and namenda, a MoCA and an interview will do just fine. The same applies to ADHD.

The psychometric approach offers a more insight into the presentation. I don't know if anyone cares anymore.
 
PsyDr said:
I differ: I think the testing is a decent approach to diagnosis.

Pretty much all DSM diagnoses can be accomplished by clinical interview. People can, and will, disguise important aspects of their lives for many reasons (e.g., malingering, embarrassment, avoiding emotional experiences, belief that something is irrelevant, etc.). Some people will have performance issues due to factors like: intelligence not commiserate with environmental demands, low conscientiousness, excessive home life demands, disinterest in subject areas secondary to personality structure, negative personality structures, lifestyle choices, medical status, secondary gain, etc.

As psychiatry has progressively narrowed their interventions to medication, such factors have become less interesting to all. If your interventions for Major Neurocognitve Disorder due to probable Alzheimer's is going to be limited to aricept and namenda, a MoCA and an interview will do just fine. The same applies to ADHD.

The psychometric approach offers a more insight into the presentation. I don't know if anyone cares anymore.
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I don't disagree. I think the testing can be helpful in a psychoeducational context, for example, in identifying what might actually be contributing to reported academic difficulties. I suppose in my mind, an evaluation just for ADHD would entail assessing for other possible explanations, and if further evaluation is needed based on information identified in the current assessment, then follow-up could be done.
 
AcronymAllergy said:
I don't disagree. I think the testing can be helpful in a psychoeducational context, for example, in identifying what might actually be contributing to reported academic difficulties. I suppose in my mind, an evaluation just for ADHD would entail assessing for other possible explanations, and if further evaluation is needed based on information identified in the current assessment, then follow-up could be done.
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If you put me in a PhD program for geometric topology, I would perform poorly and have trouble concentrating. That would probably a discordance between my FSIQ and the degree requirements, not ADHD. Stimulants would just make me feel great while accelerating my dismissal.
But no one wants to hear that their child is just average, let alone below average.
 
R. Matey said:
Maybe, but we, as far as I know, don't have PVTs for anxiety disorders where some of the psychiatric treatments can also be habit forming.
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Well anxiety is a primary symptom of benzodiazepine withdrawal so it's not like you could 'catch them faking it.'

But benzos are as much of a headache for clinicians as stimulants, so we all have different ways of trying to avoid being manipulated into the undesired role of candy dispenser.
 
PsyDr said:
If you put me in a PhD program for geometric topology, I would perform poorly and have trouble concentrating. That would probably a discordance between my FSIQ and the degree requirements, not ADHD. Stimulants would just make me feel great while accelerating my dismissal.
But no one wants to hear that their child is just average, let alone below average.
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Yep. And with adults, I've had plenty of folks come in saying or suggesting their IQ was well above average (it was not); the number of people underestimating their IQ is much lower. Although some people have responded very favorably to results that showed a lower IQ than they'd expected, as it helped them understand why certain things had been difficult for them.

I remember a fellow grad student telling me once (way back when) that they had a parent bring their child in for gifted testing. The child turned out to have a mild intellectual disability. That would be a tough feedback session.
 
PsyDr said:
If you put me in a PhD program for geometric topology, I would perform poorly and have trouble concentrating. That would probably a discordance between my FSIQ and the degree requirements, not ADHD. Stimulants would just make me feel great while accelerating my dismissal.
But no one wants to hear that their child is just average, let alone below average.
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Yeah no one was very happy about the reports the clinic made when the impression was ‘insufficient instruction.’

It was especially rough when the student was homeschooled…
 
tr said:
Right but the incentive for malingering on the part of the patient is usually negligible for treatments without addictive potential.
Nobody is coming in all hot and heavy faking their test results just to get their hands on some juicy Depakote or Paxil.
Click to expand...

True, but there may be other incentives (I'm thinking especially of PTSD diagnosis in VA clinics, for example).
 
PsyDr said:
Since we are on the acceptability of interview alone for ADHD diagnosis:


expertwitness.substack.com

Adderall Suicide

Case #231
expertwitness.substack.com expertwitness.substack.com
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But, again, prescribing is separate. You can diagnose someone with ADHD and still decide not to give stimulants. Diagnosing this person with ADHD isn't what led to the result (not the best way to say it, since it's not even clear the medication did, but hopefully you get what I'm trying to convey here).

I'm never going to know with 100% certainty if someone has ADHD. But if they meet current criteria and childhood criteria, unless I have a clear indicator of something else accounting for that, I'm going to render the diagnosis.
 
PsyDr said:
Since we are on the acceptability of interview alone for ADHD diagnosis:


expertwitness.substack.com

Adderall Suicide

Case #231
expertwitness.substack.com expertwitness.substack.com
Click to expand...

If you read that case it doesn't actually turn on the question of diagnosing ADHD per se.

And yes the lack of any indication of a meaningful interview seems like a bigger issue.
 
cara susanna said:
True, but there may be other incentives (I'm thinking especially of PTSD diagnosis in VA clinics, for example).
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Good Lord, can you imagine the backlash if VA clinicians started subjecting PTSD related complaints to validity testing?
Wouldn't want to see those headlines!!
 
PsyDr said:
Since we are on the acceptability of interview alone for ADHD diagnosis:


expertwitness.substack.com

Adderall Suicide

Case #231
expertwitness.substack.com expertwitness.substack.com
Click to expand...

I think the lack of collateral information prior to a diagnosis that would have shed light on symptoms is exactly what would have been needed to rule out a ADHD diagnosis here. I know that mention of a prior hospitalization for suicidal ideation would have sent some of alarm bells up regarding psychiatric/mood disorder being present.
 
clausewitz2 said:
If you read that case it doesn't actually turn on the question of diagnosing ADHD per se.

And yes the lack of any indication of a meaningful interview seems like a bigger issue.
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My read on it was that the defendant was found negligent for:

1) Not getting collateral information (AKA, how this reference is related to the discussion)
2) Not documenting an examination of symptoms.
3) Not ruling out substance abuse. (arguably conceptually related to the insufficiency of clinical interview alone, if you include UDS).

Are you seeing something else?
 
tr said:
Good Lord, can you imagine the backlash if VA clinicians started subjecting PTSD related complaints to validity testing?
Wouldn't want to see those headlines!!
Click to expand...

We screened, including validity testing, when deciding who got into a somewhat selective inpatient treatment program, when I was in the VA.
 
PsyDr said:
My read on it was that the defendant was found negligent for:

1) Not getting collateral information (AKA, how this reference is related to the discussion)
2) Not documenting an examination of symptoms.
3) Not ruling out substance abuse. (arguably conceptually related to the insufficiency of clinical interview alone, if you include UDS).

Are you seeing something else?
Click to expand...

These should be done in a thorough clinical interview if ADHD is the presenting concern.
 
WisNeuro said:
We screened, including validity testing, when deciding who got into a somewhat selective inpatient treatment program, when I was in the VA.
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That makes sense and is very reasonable when allocating scarce treatment resources.
I was picturing something like a required PVT prior to service connection designation decisions. That would really make some heads spin.
 
tr said:
That makes sense and is very reasonable when allocating scarce treatment resources.
I was picturing something like a required PVT prior to service connection designation decisions. That would really make some heads spin.
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Not required, but it happened frequently. We'd get referrals from SC evaluators often, and we'd definitely give PVT/SVTs.
 
PsyDr said:
My read on it was that the defendant was found negligent for:

1) Not getting collateral information (AKA, how this reference is related to the discussion)
2) Not documenting an examination of symptoms.
3) Not ruling out substance abuse. (arguably conceptually related to the insufficiency of clinical interview alone, if you include UDS).

Are you seeing something else?
Click to expand...

First off the defendant wasn't found anything, it notes the case was settled. The document is just the report of the plaintiff's expert witness. I am seeing more of an emphasis on not only #2 but also just no indication that meaningful questions were even asked about the possibility of a mood disorder. It is interesting that medmalreviewer thinks this expert witness was going way too far in his assertions about negligence.
 
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