CPT for ADHD evaluations

[JenInNewYork]

Good morning,

I’m moving into private practice and looking to piece together a battery for ADHD evaluations. I was hoping to ask a few questions. In the clinic where I most recently worked, our battery consisted of a full WAIS-IV, MMPI-2-RF (with a focus on the validity scales like F-r, Fs, and Fp-r), and CAARS & BRIEF-A (completed by different informants).

Wondering if I should look at adding a Continuous Performance Test? My read of the literature is that there isn’t much clinical utility but wanted to ask others’ thoughts. I see the IVA used in other clinics/practices and was curious about incremental validity.

Thanks so much for sharing your thoughts.

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[AcronymAllergy]

I personally probably wouldn't spring for a CPT. If it's just ADHD you're evaluating, you also don't really need the WAIS.

The only situation in which the testing might be required would be for a high-stakes eval (and/or if a school is going to require it for accommodations/IEP/etc.).

Also, the CAARS-2 is now out.

 

[JenInNewYork]

I personally probably wouldn't spring for a CPT. If it's just ADHD you're evaluating, you also don't really need the WAIS.

The only situation in which the testing might be required would be for a high-stakes eval (and/or if a school is going to require it for accommodations/IEP/etc.).

Also, the CAARS-2 is now out.

Thanks for sharing your thoughts. Makes sense to cut the WAIS (unless clinically indicated by the referral question) since there’s no specific pattern of deficits observed.

Would you suggest adding anything else?

 

[MCParent]

If youre intending to do any testing aiming for college accommodations, mcat/lsat accommodations, etc., review the latest provider reqs pdfs. An “objective” test (they mean CPT or TOVA) was required for many of the evals I did. Doesn’t mean you have to put undue weight on its results, of course.

 

[WisNeuro]

These cash pay evals? Otherwise, make sure you check with insurance companies, most here won't reimburse for any neuropsych testing for ADHD evals.

 

[texanpsychdoc]

My ADHD battery:

• Clinical interview
• GAD-7
• PHQ-9
• C-SSRS
• MMPI-3
• CAARS-2
• BRIEF-A
• MDQ
• AUDIT
• DAST-10

 

[JenInNewYork]

If youre intending to do any testing aiming for college accommodations, mcat/lsat accommodations, etc., review the latest provider reqs pdfs. An “objective” test (they mean CPT or TOVA) was required for many of the evals I did. Doesn’t mean you have to put undue weight on its results, of course.

Thank you, that’s an excellent consideration

 

[JenInNewYork]

My ADHD battery:

• Clinical interview
• GAD-7
• PHQ-9
• C-SSRS
• MMPI-3
• CAARS-2
• BRIEF-A
• MDQ
• AUDIT

Thank you for taking the time to share this list - I’d been contemplating adding the PHQ-9 and GAD-7

 

[MCParent]

Example of the MCAT reqs, which would require much more time than that battery. Eg adhd requires timed and untimed scales of academic achievement.

https://students-residents.aamc.org/media/8461/download

Def check the requirements for whatever they are looking at. Pointless to do hours of a battery only for it to be missing something that some committee decided was essential. I always formatted my reports to exactly match the order of the req documentation too.

If you do a broad symptom test (I used PAI), you can score it while they do the math portion of the WIAT or whatever, and then know if you have extra unexpected rule outs or possible comorbid conditions for which you need to go over dsm criteria (can you tell I hate seeing reports with a laundry list of dx rule outs? Ugh some people love making a huge list of those).

 

[AcronymAllergy]

Example of the MCAT reqs, which would require much more time than that battery. Eg adhd requires timed and untimed scales of academic achievement.

https://students-residents.aamc.org/media/8461/download

Def check the requirements for whatever they are looking at. Pointless to do hours of a battery only for it to be missing something that some committee decided was essential. I always formatted my reports to exactly match the order of the req documentation too.

If you do a broad symptom test (I used PAI), you can score it while they do the math portion of the WIAT or whatever, and then know if you have extra unexpected rule outs or possible comorbid conditions for which you need to go over dsm criteria (can you tell I hate seeing reports with a laundry list of dx rule outs? Ugh some people love making a huge list of those).

I agree that if it's a high-stakes eval, I'd check the requirements of whichever test the patient has in mind and be sure I'm going to meet those reqs. We used to do these when I was in grad school; the reports (and evals) were often longer to address all the identified areas, and often times the reviewing body wouldn't accept substitutes for the tests listed. Universities were typically a bit more flexible when it came to accommodations.

They were all, of course, also self-pay evals.

Edit to add: as far as additional measures, they're hit-or-miss, but if it's for adults, the CAT-A is available and includes retrospective report (and I think there's a CAT-C for children). There's also the BDEFS, which has a portion related to ADHD. And if you need a structured interview, there's the DIVA. Barkley has an ADHD-specific scale, but I think it's pretty face valid; same goes for the ASRS, which I view as more of a screening measure. You certainly wouldn't need to include all (or, technically, any) of those in the eval, but they provide some other options in addition to what's been mentioned above.

 

[cara susanna]

I do not find the CPT worth the cost or effort, personally.

 

[WisNeuro]

I do not find the CPT worth the cost or effort, personally.

Particularly with its poor validity metrics and unacceptable false positive rates.

 

[MCParent]

Particularly with its poor validity metrics and unacceptable false positive rates.

I do not find the CPT worth the cost or effort, personally.

Agree; it’s annoying that many places expect/require it or similar.
I set up a go no go task on psytoolkit that I used a few times. Free but you need to know enough to score and check again norms yourself.

 

[WisNeuro]

Agree; it’s annoying that many places expect/require it or similar.
I set up a go no go task on psytoolkit that I used a few times. Free but you need to know enough to score and check again norms yourself.

I'm not against using it as a piece of data, if the limitations are acknowledged. All of our tests have limitations, some more glaring than others. But, more often than not, I see the CPT/TOVA/Etc used as the most important indicator of whether or not a provider thinks someone does or does not have ADHD. It's just sheer incompetence.

 

[MCParent]

I'm not against using it as a piece of data, if the limitations are acknowledged. All of our tests have limitations, some more glaring than others. But, more often than not, I see the CPT/TOVA/Etc used as the most important indicator of whether or not a provider thinks someone does or does not have ADHD. It's just sheer incompetence.

Well it’s done by a computer so it’s objective and bias free.

/s

 

[Sanman]

I'm not against using it as a piece of data, if the limitations are acknowledged. All of our tests have limitations, some more glaring than others. But, more often than not, I see the CPT/TOVA/Etc used as the most important indicator of whether or not a provider thinks someone does or does not have ADHD. It's just sheer incompetence.

Is it incompetence or greed and laziness? Proper diagnosis is generally dying in healthcare because why do more work for same money? Just throw them an accommodation and a script for Ritalin. Does it matter whether the dx is correct or not if they bumped their SAT score an extra 100 points?

 

[WisNeuro]

Is it incompetence or greed and laziness? Proper diagnosis is generally dying in healthcare because why do more work for same money? Just throw them an accommodation and a script for Ritalin. Does it matter whether the dx is correct or not if they bumped their SAT score an extra 100 points?

From a pragmatic perspective, does it matter if the incompetence is borne of ignorance or greed if it is the same end result?

 

[Sanman]

From a pragmatic perspective, does it matter if the incompetence is borne of ignorance or greed if it is the same end result?

IMO, yes, because the solutions to the problem are different. Now, whether the problem will ever be addressed is a different matter altogether.

 

[PsyDr]

From a pragmatic perspective, does it matter if the incompetence is borne of ignorance or greed if it is the same end result?

Yes. That’s the difference between negligence and malice. Or manslaughter and murder.

Which affects damages.

 

[WisNeuro]

IMO, yes, because the solutions to the problem are different. Now, whether the problem will ever be addressed is a different matter altogether.

I don't see any tightening up of training or accountability in that area anytime soon.

 

[WisNeuro]

Yes. That’s the difference between negligence and malice. Or manslaughter and murder.

Which affects damages.

In legal proceedings, sure. But, I haven't come across any ADHD dx cases yet, and I assume plaintiffs are more likely to make complaints about not getting a diagnosis, when the problem is much more likely the other way around.

 

[borne_before]

Make sure you include parent data/interview - ADHD is, after all, a neurodevelopmental disorder.

 

[PsyDr]

In legal proceedings, sure. But, I haven't come across any ADHD dx cases yet, and I assume plaintiffs are more likely to make complaints about not getting a diagnosis, when the problem is much more likely the other way around.

We’ve both seen ADHD claimed as a consequence of (insert injury or emotional distress) in litigation.

 

[WisNeuro]

We’ve both seen ADHD claimed as a consequence of (insert injury or emotional distress) in litigation.

I haven't yet. I've seen previous dx of ADHD being downplayed or covered up, but in general, most of my claimants are alleging PTSD, general anxiety, or PTSD after alleged injuries.

 

[smalltownpsych]

My evaluations for ADHD mainly involve ruling out other explanations. If people really want to go the medication quick fix route and are just coming to me for the rubber stamp, it doesn’t matter what I say or do so I don’t put too much effort into it. Fill out these forms and I’ll report what they say. Not really what I want to do so fortunately I have a setup where I tend to get more of the people that want clarity and help and are reluctant to give children stimulants.

 

[cara susanna]

I personally approach it as I'd rather have a false positive than a false negative. If I can't rule out ADHD and they want a definitive answer, I'm gonna say the person has it.

 

[texanpsychdoc]

I treat ADHD evals like forensic evals..