Approach to new adult patients seeking treatment for ADHD

[SpongeBob DoctorPants]

Tomorrow I've got a 20-year-old new patient coming in. In the new patient packet he completed, he reports that he was diagnosed as a child with ADHD. He also has a history of depression and anxiety, both of which are currently doing well. The only complaint he has right now is inattentive ADHD.

I reviewed the state database for controlled meds, which goes back 5 years, and it appears that he was prescribed Vyvanse for 1 month, followed by Concerta for 1 month; these were prescribed 4 years ago. He was also prescribed Ativan, Xanax, Klonopin, and Ambien at different times, most recently 3 years ago.

There is no history of substance use. I don't suspect he is drug seeking, but because I typically see children in my practice, I can usually rely on other sources of information (such as parents and teachers) to help verify the existence of ADHD symptoms before I start a stimulant. In the case of an adult patient, unless I can speak with the parents or review past medical records, I feel that I must rely on his word, or obtain neuropsychological testing. (On that note, once I referred another young adult for testing and she never came back. I imagine one obstacle for young adult patients may be the cost of receiving testing.)

For those of you who routinely treat adult patients, what is your approach to managing complaints of ADHD? Do you refer for testing, speak with family members, or obtain past medical records before starting stimulants?

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[ryerica22]

Tomorrow I've got a 20-year-old new patient coming in. In the new patient packet he completed, he reports that he was diagnosed as a child with ADHD. He also has a history of depression and anxiety, both of which are currently doing well. The only complaint he has right now is inattentive ADHD.

I reviewed the state database for controlled meds, which goes back 5 years, and it appears that he was prescribed Vyvanse for 1 month, followed by Concerta for 1 month; these were prescribed 4 years ago. He was also prescribed Ativan, Xanax, Klonopin, and Ambien at different times, most recently 3 years ago.

There is no history of substance use. I don't suspect he is drug seeking, but because I typically see children in my practice, I can usually rely on other sources of information (such as parents and teachers) to help verify the existence of ADHD symptoms before I start a stimulant. In the case of an adult patient, unless I can speak with the parents or review past medical records, I feel that I must rely on his word, or obtain neuropsychological testing. (On that note, once I referred another young adult for testing and she never came back. I imagine one obstacle for young adult patients may be the cost of receiving testing.)

For those of you who routinely treat adult patients, what is your approach to managing complaints of ADHD? Do you refer for testing, speak with family members, or obtain past medical records before starting stimulants?

I would personally start a stimulant if he meets criteria. You can do one of the rating scales online, however, most pts are clever and now how to manipulate the answers.

BTW, what state are you in that shows you five years worth of controlled substances?

 

[WisNeuro]

I would personally start a stimulant if he meets criteria. You can do one of the rating scales online, however, most pts are clever and now how to manipulate the answers.

Most of these scales are 100% transparent and cleverness is not necessary to make it look like one has ADHD. As for the patient, get a good history, see if you can talk to parents if he'll sign an ROI. I mean, you can send them to a neuropsychologist for an appointment and testing, although testing is 100% unnecessary unless you also want to rule out another neurological disorder or learning disability. Insurance will not cover neuropsychological testing for ADHD, so you'll need something else to justify it medically or get the patient to pay out of pocket.

 

[VA Hopeful Dr]

Tomorrow I've got a 20-year-old new patient coming in. In the new patient packet he completed, he reports that he was diagnosed as a child with ADHD. He also has a history of depression and anxiety, both of which are currently doing well. The only complaint he has right now is inattentive ADHD.

I reviewed the state database for controlled meds, which goes back 5 years, and it appears that he was prescribed Vyvanse for 1 month, followed by Concerta for 1 month; these were prescribed 4 years ago. He was also prescribed Ativan, Xanax, Klonopin, and Ambien at different times, most recently 3 years ago.

There is no history of substance use. I don't suspect he is drug seeking, but because I typically see children in my practice, I can usually rely on other sources of information (such as parents and teachers) to help verify the existence of ADHD symptoms before I start a stimulant. In the case of an adult patient, unless I can speak with the parents or review past medical records, I feel that I must rely on his word, or obtain neuropsychological testing. (On that note, once I referred another young adult for testing and she never came back. I imagine one obstacle for young adult patients may be the cost of receiving testing.)

For those of you who routinely treat adult patients, what is your approach to managing complaints of ADHD? Do you refer for testing, speak with family members, or obtain past medical records before starting stimulants?

With a reliable history of diagnosis as a child, treat.

 

[randomdoc1]

I find getting a reliable developmental history from another source to be quite important. Patients are not the most reliable historians in settings concerning inattention as an adult.

 

[Sushirolls]

Patient History, and Adult ADHD Rating scale, and a Wender Utah. All 3 positive, treat. Any negatives, requires neuropsych testing.

 

[erg923]

Patient History, and Adult ADHD Rating scale, and a Wender Utah. All 3 positive, treat. Any negatives, requires neuropsych testing.

Tomorrow I've got a 20-year-old new patient coming in. In the new patient packet he completed, he reports that he was diagnosed as a child with ADHD. He also has a history of depression and anxiety, both of which are currently doing well. The only complaint he has right now is inattentive ADHD.

I reviewed the state database for controlled meds, which goes back 5 years, and it appears that he was prescribed Vyvanse for 1 month, followed by Concerta for 1 month; these were prescribed 4 years ago. He was also prescribed Ativan, Xanax, Klonopin, and Ambien at different times, most recently 3 years ago.

There is no history of substance use. I don't suspect he is drug seeking, but because I typically see children in my practice, I can usually rely on other sources of information (such as parents and teachers) to help verify the existence of ADHD symptoms before I start a stimulant. In the case of an adult patient, unless I can speak with the parents or review past medical records, I feel that I must rely on his word, or obtain neuropsychological testing. (On that note, once I referred another young adult for testing and she never came back. I imagine one obstacle for young adult patients may be the cost of receiving testing.)

For those of you who routinely treat adult patients, what is your approach to managing complaints of ADHD? Do you refer for testing, speak with family members, or obtain past medical records before starting stimulants?

1.There is no neurocognitive profile that is diagnostic of ADHD. It would be nice if there were a well validated set of attention tests (or other tests) that could identify who has ADHD and who does not, but there aren't. CPTs have been way oversold in this regard. But psychometrically, they just don't hold as much water as they claim.

2. The more measures you give, the higher the chance that you have inconsistent and/or contradictory findings. Redundancy gives many data points, but not all those data points will necessarily be useful or particularly reliable. Most redundancy in this regard does not contribute to any treatment outcome differences.

3. I would argue that a neuropsychological evaluation could be useful for some specific planning and/or treatment recs in complicated and/or treatment refractory cases.

 

[Jaxpsych]

Tomorrow I've got a 20-year-old new patient coming in. In the new patient packet he completed, he reports that he was diagnosed as a child with ADHD. He also has a history of depression and anxiety, both of which are currently doing well. The only complaint he has right now is inattentive ADHD.

I reviewed the state database for controlled meds, which goes back 5 years, and it appears that he was prescribed Vyvanse for 1 month, followed by Concerta for 1 month; these were prescribed 4 years ago. He was also prescribed Ativan, Xanax, Klonopin, and Ambien at different times, most recently 3 years ago.

There is no history of substance use. I don't suspect he is drug seeking, but because I typically see children in my practice, I can usually rely on other sources of information (such as parents and teachers) to help verify the existence of ADHD symptoms before I start a stimulant. In the case of an adult patient, unless I can speak with the parents or review past medical records, I feel that I must rely on his word, or obtain neuropsychological testing. (On that note, once I referred another young adult for testing and she never came back. I imagine one obstacle for young adult patients may be the cost of receiving testing.)

For those of you who routinely treat adult patients, what is your approach to managing complaints of ADHD? Do you refer for testing, speak with family members, or obtain past medical records before starting stimulants?

 

[Jaxpsych]

I have been treating adult ADHD for last 25 years. It was not a acceptable diagnoses in DSM at that time. Since then we have now FDA approved medication to treat Adult ADHD.
It is a real condition affecting 3-6 % of Adult. Yes there is potential for Abuse with stimulant.
New patient we generally require lot more detail, prior Psychiatric history, prior Psychological testing. filling our Adult ADHD scale, inciting family who knows patient well, and asking them to fill-out ADHD scale, and compare. We rarely send patient for new Psychological testing (only if suspect manipulation or substance use disorder) .
We start them on no stimulant medication ( Strattera/Wellbutrin) to try . this will give us some more time to see if patient is looking for treatment or looking for "DRUGS"
Then we will offer them Long acting Stimulant ( Vyvanse, Adderall XR lower dose to see how they react, ( Please do not ever prescribe short acting ADDERALL).
We insist that all stimulate patient has to come for F/U once a month to continue maintenance treatment. We will do random UDS to look for any drugs

 

[Mass Effect]

I find getting a reliable developmental history from another source to be quite important. Patients are not the most reliable historians in settings concerning inattention as an adult.

I disagree. If the patient meets criteria and there's no history of substance abuse, you treat. Making it contingent upon collateral just emphasizes the stigma of mental illness. You're essentially telling the patient they must forfeit their right to privacy before you, as a doctor, treat their medical illness.

 

[hamstergang]

I disagree. If the patient meets criteria and there's no history of substance abuse, you treat. Making it contingent upon collateral just emphasizes the stigma of mental illness. You're essentially telling the patient they must forfeit their right to privacy before you, as a doctor, treat their medical illness.

This has nothing to do with mental illness stigma. This is in a specific scenario where the diagnosis requires evidence of symptoms at a young age (so getting collateral from parents serves a specific diagnostic purpose) and where the treatment of choice is a drug of abuse (raising the incentive for people to otherwise fake/exaggerate symptoms).

 

[Mass Effect]

This has nothing to do with mental illness stigma. This is in a specific scenario where the diagnosis requires evidence of symptoms at a young age (so getting collateral from parents serves a specific diagnostic purpose) and where the treatment of choice is a drug of abuse (raising the incentive for people to otherwise fake/exaggerate symptoms).

It actually doesn't "require evidence of symptoms at a young age." The criteria is simply that symptoms must have been present at a young age. Doctors have taken it upon themselves to "require evidence." I maintain, unless there is a reason to believe the patient is lying or has a substance abuse problem/substance abuse history, you treat if the patient meets criteria. You don't need to "require" parental input for an adult and I could even argue that requiring parental input for an adult patient before treating a medical condition is not good medicine.

 

[PikminOC]

Right now, college kids are seeking stims like crazy for finals

 

[birchswing]

If he's 20, he should still be able to access a great deal of his medical records in most states. Varies widely by state, but at 20 should still be accessible.

 

[AcronymAllergy]

Barkley has done some research showing that adults are fairly accurate reporters of childhood history by the time they're in their (I believe) mid- to late-20's. Before that, it's a bit more questionable. Although research has also shown that clinical judgment alone generally isn't great at identifying exaggerated or feigned symptoms, and there can often be incentive for seeking an ADHD diagnosis.

I would say that parent report is helpful in verifying and clarifying symptom report, as parents may also have better recollection of specific details such as A) if ADHD was diagnosed, who did so and how; B) how/why and by whom was the evaluation requested; C) how did the patient perform in various academic subjects across the (childhood) lifespan in school and what if any accommodations did they receive; D) developmental and family histories; E) details of the home environment while growing up; F) what treatment(s) were provided and how effective were they; etc. Patients certainly could recall much of this themselves, but being the parents were likely privy to various details that the kiddos were not. Parents can also report on their view of how symptoms have changed over time.

For adults, I don't think formal testing is necessary in most cases, particularly those that are fairly straightforward. A thorough interview and, if you have access, a psychometrically-sound rating scale or two (face valid as they are) is generally sufficient.

 

[hamstergang]

It actually doesn't "require evidence of symptoms at a young age." The criteria is simply that symptoms must have been present at a young age.

How do you know of the presence of something without evidence of this something? This is just word play and not relevant to the discussion. My argument doesn't change if you substitute "the presence" for "evidence" in my post.

 

[cara susanna]

I've been told by our clinic's neuropsychologist that childhood history/good clinical interview and collateral symptom reports are the most important factors in assessing for ADHD.

 

[randomdoc1]

I've been told by our clinic's neuropsychologist that childhood history/good clinical interview and collateral symptom reports are the most important factors in assessing for ADHD.

As have I and the neuropsychologist at my practice published some of the major texts on ADHD.

And I know I said this a million times on this forum, when I first started pp, 85% of the new patients coming in were for inattention as adults. They were pan positive for adult symptoms and childhood symptoms. Most were also with sx of MDD and anxiety. Even when assessing for disorders not related to ADHD at all, collateral in psychiatry can be quite helpful in fleshing out the diagnosis (e.g. finding out about substance use, personality traits, treatment histories, etc.). I would argue it is bad medicine to treat with an incomplete picture. Don't get me wrong, I have treated for ADHD persisting into adulthood for some patients without getting collateral (some had very obvious childhood histories after telling me what they were like in class, actions taken by teachers, etc. )

 

[Mass Effect]

How do you know of the presence of something without evidence of this something? This is just word play and not relevant to the discussion. My argument doesn't change if you substitute "the presence" for "evidence" in my post.

It's not word play. Being accurate when discussing diagnostic clarity is not about semantics. You're using "evidence" to suggest you have to have collateral to make the diagnosis. You said "the diagnosis requires evidence of symptoms at a young age (so getting collateral from parents serves a specific diagnostic purpose)." You are justifying getting collateral by suggesting you're required to have evidence, when in fact, all you're required to have is the patient recalling symptoms at a young age.

 

[FlowRate]

It's, of course, important to rule out the many other reasons for inattention which include other untreated affective illness, sleep disorders, and substance abuse. I like my attending's approach to use of stimulants--setting concrete treatment goals. What are we going to track to know that using this medication is actually beneficial? (Grades, work performance, social relations, etc.)

It's really common to send people for testing here but the only ones I feel strong about are the ones with some diagnostic complexity (r/o another learning disorder for example.)

 

[hamstergang]

It's not word play. Being accurate when discussing diagnostic clarity is not about semantics. You're using "evidence" to suggest you have to have collateral to make the diagnosis. You said "the diagnosis requires evidence of symptoms at a young age (so getting collateral from parents serves a specific diagnostic purpose)." You are justifying getting collateral by suggesting you're required to have evidence, when in fact, all you're required to have is the patient recalling symptoms at a young age.

This is mostly false. I did not use the word evidence to justify getting collateral. The patient's report of symptoms at a young age is evidence of the presence of said symptoms. Collateral from parents is also evidence of the presence of such symptoms. We use evidence of all sorts to justify the actual presence of symptoms, and in this case I would like collateral from parents as they were adults at the time these symptoms were reportedly present.

So let's rewrite my post to satisfy you:
"This is in a specific scenario where the diagnosis requires the presence of symptoms at a young age (so getting collateral from parents serves a specific diagnostic purpose)"

There, the meaning isn't changed (especially in that this still has nothing to do with the stigma of mental illness) and I'm fine with this new wording.

 

[Trismegistus4]

It's not word play. Being accurate when discussing diagnostic clarity is not about semantics. You're using "evidence" to suggest you have to have collateral to make the diagnosis. You said "the diagnosis requires evidence of symptoms at a young age (so getting collateral from parents serves a specific diagnostic purpose)." You are justifying getting collateral by suggesting you're required to have evidence, when in fact, all you're required to have is the patient recalling symptoms at a young age.

So do you think primary care docs should prescribe opioids to everyone who says they have pain?

 

[randomdoc1]

So do you think primary care docs should prescribe opioids to everyone who says they have pain?

Yes

But more seriously, it boils down to 1) accurate assessment 2) risks versus benefits of treatment options and 3) setting realistic goals. Numbers 1 and 2 are where the slope can get slippery for stimulants in adults for sure.

 

[Mass Effect]

So do you think primary care docs should prescribe opioids to everyone who says they have pain?

They don't prescribe opioids to everyone who says they have pain any more than psychiatrists prescribe stimulants to everyone who says they have ADHD. I never said that all people should get any drug. In fact, I never make those types of generalizations. Ever. Patients are different, have different backgrounds, different risk factors, require different things. You do an exam, weigh the risk/benefit assessment, look at prior substance use/abuse, and try non-addictive medications first. But I have no problem with, after all that, a PCP deciding a patient has legitimate pain and prescribing an opioid if it's indicated and there's no substance abuse. Same goes for ADHD. Unless there's reason to doubt the patient, I don't call parents to ask how little Johnny did in school 30 years ago.

 

[SpongeBob DoctorPants]

Great discussion here. Thank you to everyone who has commented! I appreciate all of your responses. It is apparent that there are differences of opinion here, but I think each of you have made some good points. This has been very helpful.

 

[skunky386]

Hypothetically, would you feel comfortable continuing to prescribe stimulants for a clear-cut ADHD patient (good records of childhood dx, on stims for many years) who had tested positive for meth six months ago, but since then has had several random UDS that have been clean.

In the addiction clinic at my medical school the attending & fellow did prescribe long-acting stimulants for individuals w/ a history of stimulant abuse though they were mandated to get regular drug screens, I'm not sure how long they had to be clean before they would be able to start getting stims again or if this is just what these two docs did or something others do as well.

 

[Armadillos]

Seems lots of psychiatrists refer for neuropsych testing primarily to raise the barrier to getting the stimulant, so they don’t get a reputation as being easy to get controlled substances from. A sad state of affairs.

 

[LadyHalcyon]

While I completely understand the risks associated with the over-diagnosing of ADHD and the overprescribing of stimulants, the research is very clear that stimulants plus some behavioral interventions are the best treatment. Why should you not prescribe them if the person has adhd and you are certain of your diagnosis? As to the point regarding a history of substance abuse, I'm sure we are all aware that untreated adhd is a risk for addiction. Additionally, people with adhd may self-medicate with stimulants. Obviously I do agree drug screens are necessary but I also don't agree that 100% of the time a past substance abuse history should automatically preclude someone from evidence-based treatment. Also, why are people not up in arms about the RAMPANT misdiagnosis of bipolar and the horrible impact a cocktail of an antipsychotic, a mood stabilizer, and an SSRI have on the body when taken for years and years. I'm tired of seeing people who may not necessarily be prescribed an addictive substance for their diagnosis, but are basically walking obese zombies.

Sent from my SM-G950U using SDN mobile

 

[whopper]

As elitist as this sounds, I've had very few cases I've suspected of abuse in private practice, but while doing community ACT, the prevalence was high.

Poorer people have a very bad problem. Even when they really do have ADHD, they often are in times in need of money and when this happens are much more willing to abuse/sell a stimulant. People with steady incomes have more to lose by abusing but also in more abundance personality characteristics such as willing to undergo self-denial for later benefit, higher self-esteem, and better education. I don't say that in a judgmental way. I understand if a guy is struggling to pay rent he might sell a few pills. I'm not saying it's right, and I can't prescribe when a guy does that but I understand it's complicated.

Of course people on the lower end of the psychosocial spectrum, there'll be people with high resilience, self-esteem, education, etc, but I'm talking broadly and in terms of pure frequencies when you see groups of hundreds of people.

Here's what I'm talking about. Over 50% of the patients I've had in private practice, when told a substance is a controlled one and has long-term risks often times don't want to take it and if already on it want to be weaned off. When I'd refuse to give them a controlled substance, most gave responses of something to the effect of "I understand," or "I'd like the medication but you're likely doing the right thing." When I saw Medicaid patients on the bottom rung, only about 10% of those warned something was addictive had similar responses, and often times wanted more of it, and when not given it would get irritated if not worse.

It's due to this reason, and because in residency you tend to see sicker patients because of the training location that it was next to impossible to get me to prescribe a stimulant, but now days I will so long as the patient shows some testing or at least some decent history they had ADHD. Of course any patient on any controlled substance has a higher level of scrutiny placed on them, but back in my training days it was pretty much unheard of for me to prescribe a stimulant.

 

[WisNeuro]

Seems lots of psychiatrists refer for neuropsych testing primarily to raise the barrier to getting the stimulant, so they don’t get a reputation as being easy to get controlled substances from. A sad state of affairs.

I get these referrals all of the time, but turn down about 90% of them. I won't take it unless the referring provider has convinced me that there are other rule outs that also need to be tested for.

 

[psych_pa]

Poorer people have a very bad problem. Even when they really do have ADHD, they often are in times in need of money and when this happens are much more willing to abuse/sell a stimulant.

I have been wondering about this.. If you work in private practice, is there any hesitation in requesting a urine sample for this very issue? You would be able to tell if patients are not taking their prescribed medication and selling it if it does not show up in a urinalysis, but does the fear of losing your patient sometimes stop you from making this request?

Or do you ever make this request in private practice?

 

[Crayola227]

depending on the substance, patients will just pop one when they go to see you or anywhere they think urine testing/drug testing may happen

you will rarely catch diversion with a negative UDS

 

[randomdoc1]

depending on the substance, patients will just pop one when they go to see you or anywhere they think urine testing/drug testing may happen

you will rarely catch diversion with a negative UDS

Good point. Something else I do is have the patient keep the order for the UDS and I tell them I will call on a random day for them to come by and do the drop so it is a lot less predictable.

 

[psych_pa]

Thank you both.

 

[Liquid8]

As elitist as this sounds, I've had very few cases I've suspected of abuse in private practice, but while doing community ACT, the prevalence was high.

Poorer people have a very bad problem. Even when they really do have ADHD, they often are in times in need of money and when this happens are much more willing to abuse/sell a stimulant. People with steady incomes have more to lose by abusing but also in more abundance personality characteristics such as willing to undergo self-denial for later benefit, higher self-esteem, and better education. I don't say that in a judgmental way. I understand if a guy is struggling to pay rent he might sell a few pills. I'm not saying it's right, and I can't prescribe when a guy does that but I understand it's complicated.

Of course people on the lower end of the psychosocial spectrum, there'll be people with high resilience, self-esteem, education, etc, but I'm talking broadly and in terms of pure frequencies when you see groups of hundreds of people.

Here's what I'm talking about. Over 50% of the patients I've had in private practice, when told a substance is a controlled one and has long-term risks often times don't want to take it and if already on it want to be weaned off. When I'd refuse to give them a controlled substance, most gave responses of something to the effect of "I understand," or "I'd like the medication but you're likely doing the right thing." When I saw Medicaid patients on the bottom rung, only about 10% of those warned something was addictive had similar responses, and often times wanted more of it, and when not given it would get irritated if not worse.

It's due to this reason, and because in residency you tend to see sicker patients because of the training location that it was next to impossible to get me to prescribe a stimulant, but now days I will so long as the patient shows some testing or at least some decent history they had ADHD. Of course any patient on any controlled substance has a higher level of scrutiny placed on them, but back in my training days it was pretty much unheard of for me to prescribe a stimulant.

Definitely agree with this. Never ever prescribed a stimulant of any kind in training, even during my child rotation. In private I don't see those who are likely to be selling the medication on the street - usually the initial price of my consult will put them off, and if they want a quick high it will be cheaper to obtain something illegally. In the event that they come, abuse drugs and fill scripts early, I am able to control the amount dispensed from the pharmacy to some degree, cease prescribing entirely and notify the relevant state bodies in the cases of confirmed abuse.

That being said, I have had very few patients I've suspected of abuse - generally the forensic history is a giveaway, but I did have one who was probably being manipulated by a partner as two of her old scripts were filled prior to and after an admission when she hadn't been on any stimulants. There is often a lag period before I am notified of possible abuse, but once this happens I am then able to check who else has been prescribing and where they have been getting scripts filled. For me this will probably become easier in the next few years with the introduction of mandatory checks prior to script writing, which should also dissuade potential abusers.

While I find most patients are cautious regarding the nature of stimulants and keen to not be reliant and get by on the lowest possible dose, one thing which has been challenging is getting patients who claim to have been previously prescribed high doses - eg. 100mg Ritalin, 210mg Vyvanse, 120mg/day of dexamphetamine; doses more than 3 times the maximum what I would use for most of my patients. The childhood history tends to be patchy at best, and there is usually some kind of underlying personality pathology or addiction issue at play that seems to have been missed or ignored. Most have have been seen by cowboy prescribers who seem to take the view that it is ok to start patients at relatively high doses to begin with and increase them very quickly.

Can recall one young woman supposedly on 150mg of dexamphetamine. She told me she had started on 10 tablets a day and then been sacked by her lasts psychiatrist after calling him on his private number at 2am. She had also claimed he had bought her lingerie and wine! Had all the classic borderline features, and wasn't happy at being denied what she used to get. In the past I had been involved treating a similar patient on the wards taking a high dose of dexamphetamine from the same psychiatrist. This one had gone out on leave and "claimed to have "lost" her medication. My supervisor at the time did let it go the first time, but it happened a few days later and she was discharged after a heated conversation.

My approach is to start on the lowest dose, increase this slowly and only provide a limited supply initially. I have found that older adults are often more developed in terms of brain function and coping skills and seem to do just as well on lower doses. If a patient tells me they do not get any response after a few dose increases, I am more inclined to cease and swap drugs rather than continue to increase. My rationale for not using high doses is a general explanation relating to the involved drug receptors eventually becoming saturated, meaning that additional drug doses will only end up contributing to side effects as opposed to improved efficacy and most genuine patients seem to understand and accept this.

 

[ryerica22]

One question, let's say the adult or adolescent is using Cannabis (some have medical cards, while other kids are getting it from friends), but it doesn't qualify as such as a use disorder (though one might argue that even using it to help with anxiety can be abuse), am I in the wrong for still giving them a stimulant to treat their symptoms (which are not related to Cannabis use), but are causing significant impairment in their ability to work?

 

[Par4thecourse]

I disagree. If the patient meets criteria and there's no history of substance abuse, you treat. Making it contingent upon collateral just emphasizes the stigma of mental illness. You're essentially telling the patient they must forfeit their right to privacy before you, as a doctor, treat their medical illness.

There may be no history you can find, but he could be high as a kite sitting in front of you.
Privacy? When asked for input from others, I thought,"Man, these guys are professionals!" It only increased my confidence in them. My stigma for failure was no secret. It preceded me wherever I went. I wasn't forfeiting anything. I added to the relevant information that could lead to an accurate dx.

 

[Par4thecourse]

1.There is no neurocognitive profile that is diagnostic of ADHD. It would be nice if there were a well validated set of attention tests (or other tests) that could identify who has ADHD and who does not, but there aren't. CPTs have been way oversold in this regard. But psychometrically, they just don't hold as much water as they claim.

2. The more measures you give, the higher the chance that you have inconsistent and/or contradictory findings. Redundancy gives many data points, but not all those data points will necessarily be useful or particularly reliable. Most redundancy in this regard does not contribute to any treatment outcome differences.

3. I would argue that a neuropsychological evaluation could be useful for some specific planning and/or treatment recs in complicated and/or treatment refractory cases.

The findings of this study revealed that executive function patterns are different in children with ADHD compared to normal children. In this study it was also found that ADHD subtypes are also different in terms of perseveration and response inhibition domains; ADHD-C has more deficits in these domains.
Neurocognitive Profile of Children with Attention Deficit Hyperactivity Disorders (ADHD): A comparison between subtypes

Nastaran Ahmadi, MA,1Mohammad Reza Mohammadi, MD,1Seyed Mohsen Araghi,2 andHadi Zarafshan, MA1

 

[Par4thecourse]

The study compared 8-year-old children with pure attention deficit-hyperactivity disorder (ADHD) (n = 21), specific learning disorder (LD) (n = 12), and both (ADHD + LD) (n = 27) on a comprehensive set of neuropsychological measures. The tests were mainly derived from a new neuropsychological instrument, the Neuropsychological Assessment of Children. The children with ADHD were specifically impaired in the control and inhibition of impulses; the children with LD were impaired in phonological awareness, verbal memory span, and storytelling, as well as in verbal IQ. Children with both showed all of these deficiencies; they also had more pervasive attention problems and more visual—motor problems than the two other groups. All groups exhibited impaired performance in tasks of visual-motor precision and name retrieval. The latter finding may involve two different mechanisms, one related to linguistic impairment and possibly contributing to reading and spelling problems, and the other related to attentional problems.

A Comparison of Neuropsychological Test Profiles of Children with Attention Deficit—Hyperactivity Disorder and/or Learning Disorder
Marit Korkman, Aino-Elina Pesonen

 

[MacDonaldTriad]

I think some of us need to stop and listen to ourselves. I'm not sure hell exists, but we are definitely in a hand basket.

 

[Par4thecourse]

One question, let's say the adult or adolescent is using Cannabis (some have medical cards, while other kids are getting it from friends), but it doesn't qualify as such as a use disorder (though one might argue that even using it to help with anxiety can be abuse), am I in the wrong for still giving them a stimulant to treat their symptoms (which are not related to Cannabis use), but are causing significant impairment in their ability to work?

They cancel each other out

 

[WisNeuro]

You can't always apply group level differences to individual diagnosis. This has been done in ADHD, it doesn't hold up. People have tried to tell you this several times, but you refuse to listen. You have a serious lack of knowledge into how clinical research works and how the healthcare system works.

 

[MacDonaldTriad]

They cancel each other out

Hang on Wiseneuro, Par4thecourse may be on to something. Amphetamines are clearly a drug with street value, and THC demotivates and are not helpful in making parents proud, but together they may treat an underappreciated deficit that we have failed to recognize! Brilliant! Sign me up as someone who wants to profit with this market value merchandise, after all, that is why we went to medical school isn't it?

 

[clausewitz2]

Hang on Wiseneuro, Par4thecourse may be on to something. Amphetamines are clearly a drug with street value, and THC demotivates and are not helpful in making parents proud, but together they may treat an underappreciated deficit that we have failed to recognize! Brilliant! Sign me up as someone who wants to profit with this market value merchandise, after all, that is why we went to medical school isn't it?

You want your kid to grow up to be successful and a productive member of society, but you don't want a preppy kissa*s who will go into finance and end up wearing boat shoes and changing their name to Chad.

Solution? Concerta 54 mg qAM and cannabis qHS

 

[Stagg737]

You want your kid to grow up to be successful and a productive member of society, but you don't want a preppy kissa*s who will go into finance and end up wearing boat shoes and changing their name to Chad.

Solution? Concerta 54 mg qAM and cannabis qHS

I mean, in my experience your solution kind of seems to be causative of what you claim to be treating. I didn't know they started calling cocaine Concerta though...

 

[clausewitz2]

I mean, in my experience your solution kind of seems to be causative of what you claim to be treating. I didn't know they started calling cocaine Concerta though...

Titrate MJ until amotivation apparent.

 

[Par4thecourse]

The findings of this study revealed that executive function patterns are different in children with ADHD compared to normal children. In this study it was also found that ADHD subtypes are also different in terms of perseveration and response inhibition domains; ADHD-C has more deficits in these domains.
Neurocognitive Profile of Children with Attention Deficit Hyperactivity Disorders (ADHD): A comparison between subtypes

Nastaran Ahmadi, MA,1Mohammad Reza Mohammadi, MD,1Seyed Mohsen Araghi,2 andHadi Zarafshan, MA1

The findings of this study revealed that executive function patterns are different in children with ADHD compared to normal children.

That's what I said. ​

 

[WisNeuro]

 

[Liquid8]

Saw an alert for this thread and thought I’d add a quick update on one of the patients I discussed on SDN a few years ago.
A quick recap:

*This patient had seen about a dozen psychiatrists previously over the last decade or so, all who thought he was depressed and would benefit from antidepressant therapy.

*He didn’t want that, and just wanted to use methamphetamine which made him happy.

*At the end of the consultation he wanted dexamphetamine, despite admitting to procuring it illegally and not having any response on high doses.

*When I refused to prescribe him what he wanted - "Why would I prescribe something for you that you’ve told me doesn’t work?" not only did I get a long 7 page written letter but also a call from his referring GP who wasn’t happy either.

Anyway, recently I got another referral for this same patient.

It was from a different GP, who outlined that another psychiatrist had prescribed him dexamphetamine but now refused to do so. His last GP has prescribed him large quantities of diazepam, and now refused to due to going through 100 tablets a week.

Appropriately, he wanted him to be seen by an addiction medicine specialist. We only have a few of these, and they all had said no. We only have a few psychiatrists doing ADHD, and most of them refused. There were a couple who agreed, but the patient refused to pay their upfront fees.

Before declining the referral, I looked back through the appointment records, and found that shortly after seeing me he had made an appointment with a colleague, but elected to see them at their other rooms.

I also looked through new script monitoring software – there were records of diazepam being dispensed, but not dexamphetamine. This may point to script selling, but not all pharmacies here are online with the new system yet.

A bit of delayed gratification, but definitely feel I got this call right, despite the rubbish I had to put up with.

Reading over the other thread, it got me thinking that this was one of the few patients I had seen who was not open to discussing his childhood history to the point where he questioned why this was even relevant. Even the ODD/Conduct/ASPD guy I saw last week was open in discussing how he beat the crap out of teachers/parents/classmates.

 

[Par4thecourse]

Saw an alert for this thread and thought I’d add a quick update on one of the patients I discussed on SDN a few years ago.
A quick recap:


Anyway, recently I got another referral for this same patient.

It was from a different GP, who outlined that another psychiatrist had prescribed him dexamphetamine but now refused to do so. His last GP has prescribed him large quantities of diazepam, and now refused to due to going through 100 tablets a week.

Appropriately, he wanted him to be seen by an addiction medicine specialist. We only have a few of these, and they all had said no. We only have a few psychiatrists doing ADHD, and most of them refused. There were a couple who agreed, but the patient refused to pay their upfront fees.

Before declining the referral, I looked back through the appointment records, and found that shortly after seeing me he had made an appointment with a colleague, but elected to see them at their other rooms.

I also looked through new script monitoring software – there were records of diazepam being dispensed, but not dexamphetamine. This may point to script selling, but not all pharmacies here are online with the new system yet.

A bit of delayed gratification, but definitely feel I got this call right, despite the rubbish I had to put up with.

Reading over the other thread, it got me thinking that this was one of the few patients I had seen who was not open to discussing his childhood history to the point where he questioned why this was even relevant. Even the ODD/Conduct/ASPD guy I saw last week was open in discussing how he beat the crap out of teachers/parents/classmates.

Do you have success stories?