Computerized, in office, ADHD Testing

[sighchiatry]

Asking this question on behalf of a pediatric colleague.

" I've been using the original Quotient ADHD test in my office for the last ten years

Quotient ADHD Test

<p>The Quotient ADHD Test objectively measures hyperactivity, impulsivity and inattention to aid assessment of ADHD. The test reports micro-motion and analyzes shifts in attention state, helping to engage patients and guardians in the treatment planning process. </p>

www.pearsonassessments.com

Unfortunately, the original Quotient test is being phased out and not reimbursed in favor of the new and much more expensive Quotient 2.

The updated test is so expensive that it will be prohibitive to use.

So I checked out the TOVA test. It is reasonably priced, but also not as clinically useful.

The TOVA Company | Assessment and Evaluation of ADHD & Attention Deficits

The T.O.V.A. is a medical device that aids in the assessment of, and evaluation of treatment for, attention deficits including ADHD.

www.tovatest.com

Can anyone recommend an in office, computerized, ADHD test that is reasonably priced and clinically useful?

Thank you! "

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[erg923]

Can anyone recommend an in office, computerized, ADHD test that is reasonably priced and clinically useful?

No. This a poor way of thinking about how to assess this disorder. Its about level of functioning/impairment in the real world. Not about how someone does in a nice quiet office on a computer game.

Conners or Vanderbilt to parents and teachers and an in-depth history of symptom onset and home environment/dynamics.

 

[Merovinge]

Conners or Vanderbilt to parents and teachers and an in-depth history.

Vanderbilt is free and Conners is not (when reporting full score, correct?). Absolutely agree that for normal presentations of ADHD in-depth hx from school/home combined with Vanderbilt's is best practice. There are certainly cases of later presentations or other neuropsychologic comorbidity for which a full psychologic evaluation is the best. I'm very underwhelmed by the goal of computerized testing to promote diagnosis in gen peds or by mid-level therapists.

 

[WisNeuro]

Clinically useful? There are literally no standalone tests that are clinically useful in ADHD testing. The sens/spec of using these tests to identify individuals is god-awful terrible. If any testing is to be done, it needs to be part of a larger battery, where you are also trying to figure out comorbidities. Testing will not reliably discriminate ADHD from almost anything else (e.g., depression, anxiety, ASD, and on and on), so why waste the money and time at all by doing a lip service test.

 

[TexasPhysician]

Qb test

 

[WisNeuro]

The real question, is, after they completely nerfed the computerized testing code and reimbursement, what incentive do you have to even do this anymore?

 

[calvnandhobbs68]

The real question, is, after they completely nerfed the computerized testing code and reimbursement, what incentive do you have to even do this anymore?

some people will put this in an office and have patients pay cash for “adhd testing”...which basically means diagnose everyone with adhd and give them all stimulants for money.

 

[dl2dp2]

Yeah. I discussed this with some of the world experts on this topic. The gold standard remains a semi-structured clinical interview with patient/caregivers, which can in itself take 45-90 min. DIVA is a good template, CONNORS is another. TOVA is often used in research but is not particularly useful clinically.

 

[WisNeuro]

Yeah. I discussed this with some of the world experts on this topic. The gold standard remains a semi-structured clinical interview with patient/caregivers, which can in itself take 45-90 min. DIVA is a good template, CONNORS is another. TOVA is often used in research but is not particularly useful clinically.

DIVA and Connors will still give you an insanely high amount of false positives.

 

[pediatric_psydoc]

Yeah. I discussed this with some of the world experts on this topic. The gold standard remains a semi-structured clinical interview with patient/caregivers, which can in itself take 45-90 min. DIVA is a good template, CONNORS is another. TOVA is often used in research but is not particularly useful clinically.

Conners tends to overpathologize; parent and teacher Vanderbilts along with clinical interview is best IMO. If Vanderbilts yield inconsistent results, then a psychological assessment is necessary because at that point you’re evaluating if the symptoms are truly attributable to ADHD or attributable to a different condition.

 

[erg923]

because at that point you’re evaluating if the symptoms are truly attributable to ADHD or attributable to a different condition.

You are always doing that. It's just that a continuous performance on a computer in a doctor's office test does not help with that.

 

[dl2dp2]

Conners tends to overpathologize; parent and teacher Vanderbilts along with clinical interview is best IMO. If Vanderbilts yield inconsistent results, then a psychological assessment is necessary because at that point you’re evaluating if the symptoms are truly attributable to ADHD or attributable to a different condition.

I specifically asked this question: i.e. to what extent does a 5 hour neuropsych eval contribute to the differential diagnosis and clinical management. The answer is not much: you might identify say a low performance IQ, and the child is not paying attention to math classes because of that. However, this piece of information does not inform you if the child meets the criteria of ADHD otherwise. You would still go ahead and treat with meds + therapy based on your clinical judgement of severity. Inconsistent results are really a result of low symptom severity.

Neuropsych testing may be indicated if there are services specifically allocated for reasons outside of clinical diagnosis (i.e. if you need IEP for reading disability, etc), but for ADHD diagnosis per se it's not useful. There is a lot of variation of community practice, obviously--I'm citing the current expert consensus opinion. There's also little data on differential treatment efficacy, for example, if there are co-morbid X Y Z with ADHD, so existing science is of no help there. In fact, there's no good answer as to whether at lower/borderline severity, if it's better to give meds, therapy or both. There's not even great evidence suggesting that therapy works alone at all or incombination with meds (MTA).

 

[SourceOfDenial]

Vanderbilt is free and Conners is not (when reporting full score, correct?). Absolutely agree that for normal presentations of ADHD in-depth hx from school/home combined with Vanderbilt's is best practice. There are certainly cases of later presentations or other neuropsychologic comorbidity for which a full psychologic evaluation is the best. I'm very underwhelmed by the goal of computerized testing to promote diagnosis in gen peds or by mid-level therapists.

Curious—when you’re talking to a social worker do you call them a social worker, therapist, or mid level? Or is it just online that you refer to them as a mid level?

 

[pediatric_psydoc]

I specifically asked this question: i.e. to what extent does a 5 hour neuropsych eval contribute to the differential diagnosis and clinical management. The answer is not much: you might identify say a low performance IQ, and the child is not paying attention to math classes because of that. However, this piece of information does not inform you if the child meets the criteria of ADHD otherwise. You would still go ahead and treat with meds + therapy based on your clinical judgement of severity. Inconsistent results are really a result of low symptom severity.

Neuropsych testing may be indicated if there are services specifically allocated for reasons outside of clinical diagnosis (i.e. if you need IEP for reading disability, etc), but for ADHD diagnosis per se it's not useful. There is a lot of variation of community practice, obviously--I'm citing the current expert consensus opinion. There's also little data on differential treatment efficacy, for example, if there are co-morbid X Y Z with ADHD, so existing science is of no help there. In fact, there's no good answer as to whether at lower/borderline severity, if it's better to give meds, therapy or both. There's not even great evidence suggesting that therapy works alone at all or incombination with meds (MTA).

There are differences in a psychological assessment and a neuropsychological assessment. I’m not going to debate semantics but I’m in no way suggesting a 5 hour eval for a rule-out of ADHD.

Inconsistent results in a parent Vanderbilt vs a teacher Vanderbilt can mean different things, not always low symptom severity. Psychological assessments are indicated when there are concerns of possible learning disabilities, the symptoms of which teachers often mistake for symptoms of ADHD. Same happens with anxiety.

 

[pediatric_psydoc]

You are always doing that. It's just that a continuous performance on a computer in a doctor's office test does not help with that.

Of course. I meant to communicate that if clinical observations of the child, interview of the child, and collateral data from the parent during interview suggested ADHD but then reviewing Vanderbilts demonstrated inconsistent results.

 

[erg923]

I specifically asked this question: i.e. to what extent does a 5 hour neuropsych eval contribute to the differential diagnosis and clinical management.

Barring neurologically or psychiatrically complex or multiple treatment failure cases, it doesn't.
Most psychologists who bother to do research in this area, and this area of psychometric assessment know this. I think both psychiatry and pediatrics often turf these diagnostic cases because they (largely because of billing code structures, I would imagine?) do not take the extra time to gather information necessary to do a solid diagnosis. It is really not that complicated in most cases.

 

[Merovinge]

Curious—when you’re talking to a social worker do you call them a social worker, therapist, or mid level? Or is it just online that you refer to them as a mid level?

I use whatever they call themselves as a general rule of thumb which is usually therapist or counselor. In this case I am not referring to social workers, I am referring to mid level therapists (aka not PhD/PsyD psychologists) that includes LCSWs, LCPCs, masters of psychology.

 

[AcronymAllergy]

Computerized testing gives the illusion of objective/"hard" data when in reality, the results are far from being especially helpful for ADHD diagnosis. We want to believe it helps. Unfortunately, it generally doesn't. I agree with the others--I'd save the money and spend it instead on one or more of the structured interview/rating scales that can be given to patient and collateral.

When a psychologist refers to me for a neuropsychological evaluation for uncomplicated ADHD, I generally know they either aren't familiar with the research in the area, have trained in settings where they've erroneously been told neuropsych is appropriate for ADHD evals, or for whatever reason just don't want to tell the patients themselves that they don't/do have ADHD.

None of this, of course, applies to psychoeducational testing. Which in certain situations can be very helpful for ADHD (much moreso than a traditional neuropsych eval).

 

[erg923]

No. This a poor way of thinking about how to assess this disorder. Its about level of functioning/impairment in the real world. Not about how someone does in a nice quiet office on a computer game.

Conners or Vanderbilt to parents and teachers and an in-depth history of symptom onset and home environment/dynamics.

Just as a last piece for this thread, as I think its very important from both from a practice standpoint and from a diagnostic standpoint:

ADHD criteria in the DSM is a list of normal behaviors/misbehaviors until ones pre-teen years.... except that they occur with such abnormal frequency and severity, AND impair functioning on multiple fronts, AND are not due to normal or relatively adaptive reactions to familial/psychosocial chaos. Laboratory-based tests of attention (essentially) such as TOVA should probably have almost nothing to do with the clinical diagnosis of this disorder unless one has already done a myriad of talking and history gathering and still can't "make the call"...and even then the "profliles" they produce are not really diagnostically discriminating.

Do such tests contribute to the treatment planning process? No, not usually. You have ADHD. An obvious goal of any psychosocial treatments for this disorder would be teaching adaptive skills so you can better/best focus and function in various situations. Even if you come out as "normal" on a TOVA profile (but meet criteria for the disorder after a thorough assessment), I'm gonna do the same thing as above.