Evaluating for ADHD?

[Dopamemes]

Like most outpatient psychiatrists, I'm getting a huge uptick in ADHD eval requests. I used to have an excellent psychologist colleague who would do pretty comprehensive evaluations but she's gone now. I had pretty minimal ADHD training during residency (years ago) but have done plenty of self-study since then. I'm very comfortable with managing ADHD but the diagnostic part is much more challenging for me. I've tried the DIVA and ACE Plus that I've seen recommended here but feel I'm either "Feeding the answer" to the patient with the way I ask questions or am asking questions in such a veiled manner that it fails to elicit the relevant information.

Anyone have any recommendations for training or even recorded interviews of expert clinicians evaluating for ADHD? I honestly considered following some of my colleagues who just say "You need to have a psychological evaluation from a PhD psychologist before I'll treat your ADHD" but the quality of psychologists in my area is so poor that I wouldn't trust an ADHD diagnosis from most of them anyway.

---

Members don't see this ad.

 

[comp1]

I don't think a formal psychological test is that helpful clinically. It's simply a barrier some psychiatrists throw up to get these patients out of their office and have them go anywhere else. Any sort of self reported assessment (no matter how long you make it) is going to be absolutely positive because the patient knows the symptoms of ADHD and believes they have ADHD. It would be really weird if otherwise. If you really want to do some sort of detailed assessment for this, it's all going to be in history. You're going to want to talk to family members about them growing up, in broad generalities. Like, how did they do in school? And then just let the family member talk. Then you're going to need to take a holistic view at the patient's functioning at present. How is work going? You don't ask any sort of leading questions about focus or anything like that. When was their last promotion? Have they been fired or reprimanded? Why? Now their relationships. What are they like? How do they interact with other people? What does their partner like about them? What don't they? Again, no leading, no diagnostic criteria directly asked because if you do, it will be positive. If this all sounds like a lot of effort you neither have time for nor will be reimbursed for, you are 100% correct. This is why some psychiatrists try to get people seeking ADHD treatment out of their office through any barrier possible.

 

[clausewitz2]

Like most outpatient psychiatrists, I'm getting a huge uptick in ADHD eval requests. I used to have an excellent psychologist colleague who would do pretty comprehensive evaluations but she's gone now. I had pretty minimal ADHD training during residency (years ago) but have done plenty of self-study since then. I'm very comfortable with managing ADHD but the diagnostic part is much more challenging for me. I've tried the DIVA and ACE Plus that I've seen recommended here but feel I'm either "Feeding the answer" to the patient with the way I ask questions or am asking questions in such a veiled manner that it fails to elicit the relevant information.

If you're using either of these instruments as intended and the patient is not actually answering the questions in a way that is consistent with the ADHD diagnosis, it is a strong indicator that they should not have an ADHD diagnosis. Best to also obtain collateral whenever possible in a separate conversation (sometimes people have very poor insight into what they were like in the past, especially as kids). What gives you pause about concluding that the negative result is a true negative in these cases?

 

[R. Matey]

In addition to the clinical interview (where I use a structured interview, rating scales, and a collateral interview), the bulk of my evaluations are focused on identifying demonstrable clinically significant impairment that is directly attributable to ADHD, rather than simply strict symptom reporting because I have also found that people are aware of the symptom criteria. Also spend a good amount of time on differentials.

 

[annoyedpsychiatrist]

above advice is all solid. my viewpoints:

1. Ask open ended questions. Pull it out of the patient, dont feed the answer, agreed with that
2. Collateral from spouse can often be useful
3. Identify clear deficits in multiple domains (work, home, college, etc)
4. Ensure no obvious addiciton issues
5. Asking why are they here now? What was the final straw that made them seek help for this?
6. What is the real goal of the medication? By starting the ADHD medication, what are we looking at improving? Ensure theres a real tangible, measurable goal. Not just "i want to focus better".
7. Rule out things that can mimic ADHD or worsen concentration
8. Try to recognize a pattern of impulsivity/attention/concentration issues originating in childhood
9. Ensure no obvious sleep disorder, sleep deficit
10. Ensure no significant cardiac history


Once youve answered all these and came to to the conclusion the risk of them receiving an ADHD medication low, and the potential for improvement is significantly higher, than the majority of the time it will be ok. Often you can recognize signs of hyperactivity (not always inattention) during clinical interview. The vast majority of my people want ADHD medications for the right reason. Some people are obvious in that they shouldnt be on ADHD medications/drug seeking. Sometimes you will get it wrong, no one is 100%. Better to help 100 people and be wrong 1 time, than help no one.

I had a 55 year old today i just started on a stimulant. However, i did due diligience with him. Pattern of deficits in school/work setting. Verified by spouse. Patient was very open/collaborative; first we tried ensurng his anxiety medications were under control. We ensured compliance with CPAP (which he is very compliant per documentaiton). he has no criminal/drug history. He has more than patient; we tried 3 months of other interventions first including nonstimulants. So ultimately decided on a stimulant first. Ive found most people who genuinely want help are willing to go through steps and are less "I NEED ADDERALL!". Because they want to solve the actual issue.

 

[clozareal]

What I gained from a CAP fellowship that I'm not seeing others mention in this thread is to get a good developmental history. It's required by the diagnostic criteria to have symptoms of ADHD prior to age of 12. A few thoughts just on the top of my head, not comprehensive by any means.

1. What was their childhood like? What was their family make up in terms of parents, siblings, grandparents, other caregivers? Parental occupation, educational background, social situations. How did parents reward them for good behavior? How did parents manage undesired behavior? What messages were they given by their parents about their behavior and academic performance growing up particularly in grade school?
2. School history, with particular emphasis in elementary and middle schools. What did teachers say about them? If they tell me that they were perfect student with no disruptions in class, teacher concerns, parental concerns, or issues in college, then the pretest probability for ADHD is really low. I would want a damn good reason why so many check points missed their "ADHD."
   • Some of these include parental neglect, parental inattention due to their own ADHD or their focus on work or other siblings or something else, that parents did everything for them in school so they didn't have a chance to prove their difficulties in school, school that wasn't very hard or attentive including schools in other countries where ADHD isn't widely regarded, etc.
   • If the patient has school records such as grades/report cards especially with comments from the teacher, that's even better. ADHD often presents its first symptoms around age 3-6 so getting an idea from collateral about their behaviors, mood, trouble they got into during preschool-age and early elementary school can be very helpful.
3. Hyperactivity/impulsivity in this age group will often come with injuries, accidents, broken bones, concussions, etc. so I ask about those.
4. Pregnancy, prenatal history, exposure to medications/drugs in utero, complications of delivery or newborn period. If you don't ask, you won't know. Did the mother drink, smoke weed (commonly missed), use medications, use drugs
5. Developmental trauma including neglect, harsh punishments such as physical punishments or extreme verbal yelling.
6. Developmental milestones and any delays here. Sitting, walking, first words, and toilet training. Many people with ADHD will struggle with nocturnal enuresis and incomplete potty training until later years (I have adults with ADHD who still struggle with this). Social milestones are really important too because social interactions require complex attention in paying attention to what the other person is saying while at the same time thinking about how you'll respond. Maintaining friendships also requires a higher level of attention that is deficient in ADHD.
7. A good family history. ADHD is about 75% heritable and about 1/3 of family members who have ADHD will have another family member with ADHD.
8. Sleep history is so important. What time was their bedtime and wake up time growing up? What times are they currently? Sleep deprivation leads to a cumulative deficit in vigilant attention and lower inhibitory control (i.e., impulsivity). Sleep deprivation in early childhood is associated with a higher risk of ADHD in middle childhood. Interestingly, stimulants which are known to cause initial insomnia has been calming for my patients so that at the end of the day, some patients paradoxically actually feel more tired and sleep better. Of course, make sure they don't have sleep apnea, narcolepsy, non-24 hour circadian rhythm, delayed sleep phase disorder (really comorbid with ADHD, can lead to adolescent-onset ADHD, and treatment is different), or some other sleep disorder.
9. Making sure you don't miss any undiagnosed autism is important too. If someone tells me they think their family member has ADHD because they're only interested in 1-2 things and won't do anything else and concerned about hyperfocus, I would want to make sure that's not in the restricted interests domain of autism instead since the phenomenology of ADHD is about novelty seeking rather than comfort in the small number of items and rigidity when trying to move away from that. Hyperfocus usually doesn't come alone as in ADHD it comes often with lack of focus when they are not hyperfocused.

 

[FlowRate]

Will come back if I think of other great advice to add, but lots of excellent responses so far.

FWIW, in a large psychiatry department with a range of physicians in all career stages, who take all comers (no cherrypicking), the rate of stimulant prescribing is between 0.1 and 0.4, with a fairly even distribution across that range, although weighted slightly toward the lower end of that range. If you use that as a proxy for rate of ADHD diagnosing in a broad psychiatric clinic sample (minus medicaid but with medicare), then roughly that proportion of each psychiatrist's panel has an ADHD diagnosis. (Obviously a gross measure, I don't have the panel diagnosis breakdowns and neglects stims used for other reasons and ADHD diagnoses not on stims.)

Just in case that helps with your sense of whether you're being too liberal or stingy with the diagnosis. FWIW, my rate is 0.14. (That's all patients, not just patients who present with ADHD as chief complaint.)

 

[docloufan]

I know ADHD is not an old diagnosis, but its not really "new" either. I cannot understand why psychiatrists make this so hard on themselves? It takes some time (usually) but is really not that ****ing complicated.

Is it the stimulant Rx fear? Malingering? Missing something cause you feel rushed? This "you need to have a psychological evaluation from a PhD psychologist" is freaking ancient.... and is poor accountability and due diligence to boot. What's this about???

This really has to be bread-and-butter stuff for psychiatrists now. Should have been all along, really. And I am sure everyone can relate to the OPs last statement of "I wouldn't trust an ADHD diagnosis from most of them anyway." Well...please don't. Every treating Psychiatrist is accountable for the "diagnosis" they are treating. This shouldn't even be a question, folks.

 

[clausewitz2]

I know ADHD is not really and old diagnosis, but its not really "new" either. I cannot understand why psychiatrists make this so hard on themselves? What is this about?

Is it stimulant Rx fear? Malingering? Missing something cause you feel rushed? This "you need to have a psychological evaluation from a PhD psychologist" is freaking ancient.... and is poor accountability and due diligence to boot. Really has to be bread-and-butter stuff for psychiatrists now. Should have been all along, really. And I am sure everyone can relate to the OPs last statement of "I wouldn't trust an ADHD diagnosis from most of them anyway." Well...please don't. Every treating Psychiatrist is accountable for the "diagnosis" they are treating. This shouldn't even be a question, folks.

Hyperkinetic kids were being treated with stimulants almost as soon as they were commercially available in the 30s so it's not that new of an idea.

 

[docloufan]

Hyperkinetic kids were being treated with stimulants almost as soon as they were commercially available in the 30s so it's not that new of an idea.

Exactly. Ancient stuff. Almost no one alive remembers the 30s and 40s. What a shame.

Love the refence to "Hyperkinetic"....the grand ole days when no one outside Psychiatry/Psychology knew what the hell we meant, or how to actually interact with our patients.

 

[FlowRate]

I know ADHD is not an old diagnosis, but its not really "new" either. I cannot understand why psychiatrists make this so hard on themselves? What is this about? It takes some time (usually) but is really not that ****ing complicated. Psychiatry 102???

Is it the stimulant Rx fear? Malingering? Missing something cause you feel rushed? This "you need to have a psychological evaluation from a PhD psychologist" is freaking ancient.... and is poor accountability and due diligence to boot. Really has to be bread-and-butter stuff for psychiatrists now. Should have been all along, really. And I am sure everyone can relate to the OPs last statement of "I wouldn't trust an ADHD diagnosis from most of them anyway." Well...please don't. Every treating Psychiatrist is accountable for the "diagnosis" they are treating. This shouldn't even be a question, folks.

I think the concept of people going undiagnosed until their 40's and all parroting the same social media "examples" of (mild) deficit is a new phenomenon. Also, well controlled prospective studies showed that a significant chunk of people developed out of ADHD. It's all retrospective recall studies that are supporting the idea that it's a life-long illness for the majority.

So while the concept may not be new, the current cultural moment with explosion in demand for diagnosis and treatment in seemingly functional adults without a childhood history of diagnosis IS a new thing. It's led to a gargantuan rise in diagnosis and prescription of stimulant medications in adults, which may not be as risky as opioids but are not wholly benign.

 

[docloufan]

I think the concept of people going undiagnosed until their 40's and all parroting the same social media "examples" of (mild) deficit is a new phenomenon. Also, well controlled prospective studies showed that a significant chunk of people developed out of ADHD. It's all retrospective recall studies that are supporting the idea that it's a life-long illness for the majority.

So while the concept may not be new, the current cultural moment with explosion in demand for diagnosis and treatment in seemingly functional adults without a childhood history of diagnosis IS a new thing. It's led to a gargantuan rise in diagnosis and prescription of stimulant medications in adults, which may not be as risky as opioids but are not wholly benign.

One issue may be that Psychiatrists have come to a conclusion that they have to "treat" everything that comes to them. And, lets be clear, this is multiple decades in the making...not just to blamed on the hospitals, RVUs, patients, and/or CPT codes over the years.

I am sure you are well aware of your colleagues on here who have argued emphatically that children do NOT "just age out of ADHD?" What do we think this is about?

Do we think psychiatry wants to "treat" too much?

 

[Ceke2002]

Hyperkinetic kids were being treated with stimulants almost as soon as they were commercially available in the 30s so it's not that new of an idea.

First described by Sir Alexander Crichton in 1798, also described by Sir George Frederic Still in 1902. I believe it's Dr Charles Bradley in the 1930s with Benzedrine you're thinking of. Granted it wasn't included in the first DSM, but DSM II in 1968 had the precursor name of 'Hyperkinetic Reaction of Childhood'. So yeah definitely not that new of a concept.

It would be interesting to compare historical approaches to treatment across different countries. South Australia circa 1975 the first line approach to treatment seemed to be more along the lines of behavioral modification techniques, and dietary changes (avoiding certain food dyes, for example). I don't really remember meeting other kids with ADHD who were on medication until the early 80s.

 

[clozareal]

I think the concept of people going undiagnosed until their 40's and all parroting the same social media "examples" of (mild) deficit is a new phenomenon. Also, well controlled prospective studies showed that a significant chunk of people developed out of ADHD. It's all retrospective recall studies that are supporting the idea that it's a life-long illness for the majority.

The biggest study in ADHD is the MTA study and has been following people for... 25 years now? They screened kiddos when they were young and determined the control group NOT to have ADHD. However, when they evaluated them as adults, something like 90% (I forget the exact number but a vast majority) of them believed they had ADHD as a kid and reported symptoms as such even when they were formally ruled out as having it!

 

[Ceke2002]

The biggest study in ADHD is the MTA study and has been following people for... 25 years now? They screened kiddos when they were young and determined the control group NOT to have ADHD. However, when they evaluated them as adults, something like 90% (I forget the exact number but a vast majority) of them believed they had ADHD as a kid and reported symptoms as such even when they were formally ruled out as having it!

Do you have a link to the study (that is accessible to lay persons to read)? Please and thank you. I'm on a medical studies reading binge at the moment. 🙂

 

[Dopamemes]

I know ADHD is not an old diagnosis, but its not really "new" either. I cannot understand why psychiatrists make this so hard on themselves? It takes some time (usually) but is really not that ****ing complicated.

Is it the stimulant Rx fear? Malingering? Missing something cause you feel rushed? This "you need to have a psychological evaluation from a PhD psychologist" is freaking ancient.... and is poor accountability and due diligence to boot. What's this about???

This really has to be bread-and-butter stuff for psychiatrists now. Should have been all along, really. And I am sure everyone can relate to the OPs last statement of "I wouldn't trust an ADHD diagnosis from most of them anyway." Well...please don't. Every treating Psychiatrist is accountable for the "diagnosis" they are treating. This shouldn't even be a question, folks.

Yeah, well, it is what it is. I can't travel back through time and yell at my residency program for not having more ADHD training so here I am trying to educate myself. Providing resources would be more helpful than just yelling into the clouds. If that's more cathartic for you though, go ahead and keep yelling.

 

[clozareal]

Anyone have any recommendations for training or even recorded interviews of expert clinicians evaluating for ADHD? I honestly considered following some of my colleagues who just say "You need to have a psychological evaluation from a PhD psychologist before I'll treat your ADHD" but the quality of psychologists in my area is so poor that I wouldn't trust an ADHD diagnosis from most of them anyway.

Adult ADHD: Comprehensive Diagnosis and Treatment

Welcome to our course on treating ADHD in adults. Throughout these modules, we will dive into the latest approaches to understanding, diagnosing, and managing ADHD in adult patients. Whether you're refining your skills or building a foundation, this course is designed to provide practical...

www.thecarlatreport.com

 

[clozareal]

Do you have a link to the study (that is accessible to lay persons to read)? Please and thank you. I'm on a medical studies reading binge at the moment. 🙂

I'll need to find it. I forget exactly where i read it. Was it from here? or here?

 

[docloufan]

Yeah, well, it is what it is. I can't travel back through time and yell at my residency program for not having more ADHD training so here I am trying to educate myself. Providing resources would be more helpful than just yelling into the clouds. If that's more cathartic for you though, go ahead and keep yelling.

I see. I noticed you didn't answer any of the questions. What's that about?

 

[Ceke2002]

I'll need to find it. I forget exactly where i read it. Was it from here? or here?

Second link works, thank you. 😀

 

[FlowRate]

One issue may be that Psychiatrists have come to a conclusion that they have to "treat" everything that comes to them. And, lets be clear, this is multiple decades in the making...not just to blamed on the hospitals, RVUs, patients, and/or CPT codes over the years.

I am sure you are well aware of your colleagues on here who have argued emphatically that children do NOT "just age out of ADHD?" What do we think this is about?

Do we think psychiatry wants to "treat" too much?

Those are actually great points.

First two questions--I think there are a bunch of simultaneous things going on. Recent (lower quality, often retrospective) research promulgating an expanded concept of what qualifies for ADHD and what symptoms should be considered part of the syndrome. Pressure from patients to "treat" their difficulty working from home; working a self-directed job from home is ****ing hard, but we all pretended it was normal 'because COVID and we have to.' Pressure on social media and a new paradigm of "how ADHD presents in X" or "underrecognized signs of ADHD" that seep their way into professionals who hear these things parroted endlessly. But there's also a known percentage of people who do not develop out of ADHD, it's just likely much smaller than the current cultural moment would have us believe and neglecting the adults with true persistent ADHD would be inappropriate. Plus a lot of professionals in the MH field have themselves received ADHD diagnoses and stimulants and found them very helpful, which I think affects how some of those people approach the subject. (I have yet to hear of a patient seeing an "ADHD therapy specialist" who doesn't self-disclose in the first session that they also have ADHD...) I don't think I've even covered all of it.

Absolutely, especially in an age where many of us are no longer primary therapists for our patients. "I can help you with a medication or I can refer you to a therapist but the variability in community therapists is so great that I have absolutely no clue what sort of quality of therapy you'll be getting." While there are many things I don't miss about being a "therapist" therapist (hour sessions weekly etc.), I do sometimes miss having more direct input over that piece of patients' care. It takes a lot of skill to determine when medications adjustments aren't the best next step and to help a patient understand that does not mean a lack of care. (This seems to be a common differentiator between NP's and MD's / more and less skilled psychiatrists.)

The biggest study in ADHD is the MTA study and has been following people for... 25 years now? They screened kiddos when they were young and determined the control group NOT to have ADHD. However, when they evaluated them as adults, something like 90% (I forget the exact number but a vast majority) of them believed they had ADHD as a kid and reported symptoms as such even when they were formally ruled out as having it!

Absolutely, and here I was just coming back to this thread after thinking about how much it feels like the "recovered memories" thing all over again.

 

[splik]

Hyperkinetic kids were being treated with stimulants almost as soon as they were commercially available in the 30s so it's not that new of an idea.

Sure, but the concept of hyperkinetic disorder and minimal brain dysfunction stand in stark contrast to the typical adult patient gracing our consulting rooms these days. They rarely have hyperactivity and instead complain of inattentiveness. The first paper I can find on minimal brain dysfunction in adults is from 1967. It was not until the 90s that adults were regularly taking stims for ADHD, and not until the early 2000s that it really became popular, and was only since 2012 that it really caught on fire. During that time the threshold for a diagnosis of ADHD has vastly expanded and the threshold for getting a diagnosis is almost non-existent. Adult ADHD is a diagnosis of late capitalism par excellence.

Like most outpatient psychiatrists, I'm getting a huge uptick in ADHD eval requests. I used to have an excellent psychologist colleague who would do pretty comprehensive evaluations but she's gone now. I had pretty minimal ADHD training during residency (years ago) but have done plenty of self-study since then. I'm very comfortable with managing ADHD but the diagnostic part is much more challenging for me. I've tried the DIVA and ACE Plus that I've seen recommended here but feel I'm either "Feeding the answer" to the patient with the way I ask questions or am asking questions in such a veiled manner that it fails to elicit the relevant information.

Most patients who present for a ADHD eval do not have ADHD. You have to get comfortable with telling them that. 1 in 4 adults thinks they have ADHD, and even if we believe as is claimed that 6% of adults have ADHD that means the vast majority of those seeking a diagnosis do not.

A good proportion do have ADHD, but many patients are stimulant seeking, have unrealistic expectations of their own productivity (or have such expectations foisted upon them by their professions), have anxiety disorders, trauma-related disorders, sleep disorders, mood disorders, substance use disorders, TBI, or personality disorders etc. In some populations (e.g. college age students), malingering/exaggeration is found in as many as 50%. As I've discussed above, "adult ADHD" includes a subset of hysterical patients who are suggestible and cling to the latest diagnosis as a way of life.

It's often the patients who present with something else who actually have undiagnosed ADHD.

 

[Liquid8]

I agree with a lot of what has already been written. For ADHD most of my assessment is centred around exploring their childhood, education, work performance and home life – which also includes things like how they manage their finances, shopping and driving. Eg. Spouse who pays all the bills because when the patient was given this responsibility it just never happened and the had their power cut off for example. Then you can look at what the were like when they lived on their own, or in a share house etc.

Never having any problems in childhood or early education usually leans me away from ADHD – but anxiety/OCPD/perfectionism is quite common. I tend to be more wary of those who claim “I can’t remember anything about my childhood”, but will often enquire about things later on in the interview. And it will flow into other areas of the assessment. Eg. someone who always “leaves things to the last minute” re: assignments could be procrastinating or a perfectionist (who won’t submit because it’s not 100% to their liking), and later on if I ask about finances the latter will likely be highly organized in managing their bills, tax affairs etc; or following instructions with tasks like cooking or putting together furniture, with the perfectionist/anxious types being more rigid in their application of such things.

I started out by seeing a lot of patients diagnosed in childhood who graduate out of their pediatricians and child psychiatrists to adult services. What I’ve seen over the years is that hyperactivity tends to reduce over time which I hypothesize is probably due to a combination of frontal lobe development, societal pressure on what constitutes acceptable behaviour, and more outlets like extreme sports. I think I have a whole cohort who do stuff like rock climbing and bouldering, which probably burns off the excess energy.

What does seem to persist is the inattentive features, with one classic example being the tradesmen who leaves school early to do an apprenticeship. They aren’t great with conventional learning, but do well on the tools and with practical tasks so they stop their medication. Usually when they qualify they work for someone for a while, but many decide they can go into business for themselves – and that’s where we start to see problems with admin/paperwork tasks like invoicing, quotes, paying suppliers answering emails etc which parallels difficulty with things like homework. Some of them will have a business partner or spouse who can help with some of those things – but the ones who don’t often get referred because they want to go back on medication.

What I also notice is that they often need less medication than they were previously taking in childhood – again, I put this down to frontal lobe development and the accumulation of coping strategies over time. I often use this as a way to dissuade people asking for higher doses of medication just because the are bigger or overweight compared to the average. This has also helped me to better distinguish from potential drug seekers or those with an addictive personality. When anyone tells me they need increasingly more and more of a stimulant over a short period it starts to ring alarm bells, and moreso if they do it themselves without consulting me first.

The first one I remember was taking 4x the prescribed amount of Seroquel and clonazepam when I first saw him. Later on we tried to get him off alcohol, but in his mind that meant he needed cannabis. And when we tried to get him off cannabis, he always felt he had to drink to make up for it. Sometime later he saw another psychiatrist who diagnosed him with ADHD – I can remember receiving the letter and thinking it seemed plausible, but it had never really crossed my mind as we could never work through the drug issues. They prescribed him a small quantity of dexamphetamine, and true to form he had no self-control and ended up overdosing and becoming psychotic.

It’s not limited to stimulants either – I had another patient with alcohol dependence and depression who I started on Venlafaxine, with the instruction to start on one 75mg tablet and increase it to 150mg after a week if there were no side effects. About two weeks in he called and asked if he could increase the dose, but he was already taking 5 tablets and wanted to go to 450mg! At the time I had just pegged him as someone who would do whatever he felt like, so made a mental note that certain meds like tricyclics and lithium would be off the table.

The core belief all of these patients have seems to be, “It makes me feel good, so I thought I’d be ok to take more.” This doesn’t mean they don’t have ADHD, but it has important implications in terms of treatment.

 

[clausewitz2]

Sure, but the concept of hyperkinetic disorder and minimal brain dysfunction stand in stark contrast to the typical adult patient gracing our consulting rooms these days. They rarely have hyperactivity and instead complain of inattentiveness. The first paper I can find on minimal brain dysfunction in adults is from 1967. It was not until the 90s that adults were regularly taking stims for ADHD, and not until the early 2000s that it really became popular, and was only since 2012 that it really caught on fire. During that time the threshold for a diagnosis of ADHD has vastly expanded and the threshold for getting a diagnosis is almost non-existent. Adult ADHD is a diagnosis of late capitalism par excellence.

Minor point at the end of the day, but that's really because minimal brain dysfunction as a label was a deliberate attempt to more accurately rename minimal brain damage, a diagnostic concept that goes back at least until Alfred Strauss and co in the 40s. It is different in that people were still mostly applying this idea to children but it still was getting a lot of kids who were not the classic hyperkinetic ones.

Given the almost universal popularity of amphetamines as a general kind of life tonic before they became controlled substances (especially in the 50s and 60s) I think 'late-stage capitalism' explains very little about the upsurge in prescribing in the past few decades. I don't disagree with your timeline overall though.

 

[aim-agm]

Never having any problems in childhood or early education usually leans me away from ADHD – but anxiety/OCPD/perfectionism is quite common. I tend to be more wary of those who claim “I can’t remember anything about my childhood”, but will often enquire about things later on in the interview. And it will flow into other areas of the assessment. Eg. someone who always “leaves things to the last minute” re: assignments could be procrastinating or a perfectionist (who won’t submit because it’s not 100% to their liking), and later on if I ask about finances the latter will likely be highly organized in managing their bills, tax affairs etc; or following instructions with tasks like cooking or putting together furniture, with the perfectionist/anxious types being more rigid in their application of such things.

Agreed. As with many things in psychiatry, interrogating the underlying process is important to understand the implications of the symptom. Submitting things at the last minute because they want to use all available time to make the submission as good as possible is very different from submitting things at the last minute because they need the pressure of the deadline to maintain focus.

One thing that can be tricky is the differentials for ADHD can develop because of the condition, e.g. OCPD traits or drive to be excessively organized as an adaptation to counterbalance difficulties with organization due to ADHD, or someone who feels generally anxious that they have forgotten something...because they often forget things because of their ADHD.

What does seem to persist is the inattentive features, with one classic example being the tradesmen who leaves school early to do an apprenticeship. They aren’t great with conventional learning, but do well on the tools and with practical tasks so they stop their medication. Usually when they qualify they work for someone for a while, but many decide they can go into business for themselves – and that’s where we start to see problems with admin/paperwork tasks like invoicing, quotes, paying suppliers answering emails etc which parallels difficulty with things like homework. Some of them will have a business partner or spouse who can help with some of those things – but the ones who don’t often get referred because they want to go back on medication.

"Patient is experiencing dysfunction as an executive because of their executive dysfunction."

What I also notice is that they often need less medication than they were previously taking in childhood – again, I put this down to frontal lobe development and the accumulation of coping strategies over time. I often use this as a way to dissuade people asking for higher doses of medication just because the are bigger or overweight compared to the average. This has also helped me to better distinguish from potential drug seekers or those with an addictive personality. When anyone tells me they need increasingly more and more of a stimulant over a short period it starts to ring alarm bells, and moreso if they do it themselves without consulting me first.

The core belief all of these patients have seems to be, “It makes me feel good, so I thought I’d be ok to take more.” This doesn’t mean they don’t have ADHD, but it has important implications in terms of treatment.

I wonder about a rule of thumb that clinical appropriateness of a stimulant is inversely proportional to desire to be on a stimulant.

One pattern I see in people who do have ADHD is a degree of aversion to medications. They dislike needing to take a medication or taking medication consistently, they want to be less reliant on medication (especially because they worry about forgetting to take meds). They often ask (or like the idea of) not taking medications (or taking less) on less cognitively demanding days. They tend to be quite enthusiastic about the idea of non-controlled options because they are more convenient to be on. Not a diagnostic pattern by any means, but I find it does help to differentiate people seeking treatment from people who want amphetamines.

 

[romanticscience]

I wonder about a rule of thumb that clinical appropriateness of a stimulant is inversely proportional to desire to be on a stimulant.

Reminds me of the rule I heard while working in the psych ED. "Discharging the people who want to be there and admitting those who don't."

 

[Merovinge]

Minor point at the end of the day, but that's really because minimal brain dysfunction as a label was a deliberate attempt to more accurately rename minimal brain damage, a diagnostic concept that goes back at least until Alfred Strauss and co in the 40s. It is different in that people were still mostly applying this idea to children but it still was getting a lot of kids who were not the classic hyperkinetic ones.

Given the almost universal popularity of amphetamines as a general kind of life tonic before they became controlled substances (especially in the 50s and 60s) I think 'late-stage capitalism' explains very little about the upsurge in prescribing in the past few decades. I don't disagree with your timeline overall though.

Just to clarify, you do or do not think the NP online pill mills cranking out immediate release amphetamines following COVID era relaxation of laws for prescribing these medications explains part of the upsurge in prescribing?

 

[clausewitz2]

Just to clarify, you do or do not think the NP online pill mills cranking out immediate release amphetamines following COVID era relaxation of laws for prescribing these medications explains part of the upsurge in prescribing?

Oh I think that is a driver of it, though it's important to note the trend started well before COVID and the legal changes you mention. You can go back much farther than that on this very forum to find threads complaining about an uptick in evaluations for ADHD in adults.

Amphetamines also used to be sold over the counter for a number of ailments, chief among them, and they were very widely used in the mid 20th century for vaguely neurasthenic complaints. i'm just not sure 'late stage capitalism' explains much about what's happening, only in part because that doesn't really mean anything.

 

[Merovinge]

Oh I think that is a driver of it, though it's important to note the trend started well before COVID and the legal changes you mention. You can go back much farther than that on this very forum to find threads complaining about an uptick in evaluations for ADHD in adults.

Amphetamines also used to be sold over the counter for a number of ailments, chief among them, and they were very widely used in the mid 20th century for vaguely neurasthenic complaints. i'm just not sure 'late stage capitalism' explains much about what's happening, only in part because that doesn't really mean anything.

Per chat GPT
Key characteristics typically associated with late-stage capitalism include:

1. Excessive corporate power: Large corporations hold significant sway over both the economy and politics, often prioritizing profit maximization over human welfare, environmental sustainability, and fair competition.
2. Commodification of all aspects of life: Under late-stage capitalism, almost everything becomes a product or service to be bought and sold, including personal data, relationships, and basic human needs like healthcare and education. There’s a growing market for things like experiences and emotional labor, which didn’t exist to the same extent before.
3. Worker exploitation: Despite advancements in technology and productivity, wages for many workers stagnate while the cost of living rises. The gig economy, low-wage labor, and precarious employment are often highlighted as examples of how the system exploits workers.

I certainly can see an argument that PE/VC owned tele health has excessive corporate power that prioritizes profit over human welfare. That healthcare has been commodified, and that workers are being exploited (although I still feel there is a tremendous amount of personal agency those NPs should be taking, I can at least comprehend getting out of school and feeling a need to get a job in a tough market).

I don't think late-stage capitalism is the only reason amphetamines are exploding in prescriptions, there are obviously others as well, but I would want to hear more about why those things aren't part of the story.

 

[clausewitz2]

Per chat GPT
Key characteristics typically associated with late-stage capitalism include:

1. Excessive corporate power: Large corporations hold significant sway over both the economy and politics, often prioritizing profit maximization over human welfare, environmental sustainability, and fair competition.
2. Commodification of all aspects of life: Under late-stage capitalism, almost everything becomes a product or service to be bought and sold, including personal data, relationships, and basic human needs like healthcare and education. There’s a growing market for things like experiences and emotional labor, which didn’t exist to the same extent before.
3. Worker exploitation: Despite advancements in technology and productivity, wages for many workers stagnate while the cost of living rises. The gig economy, low-wage labor, and precarious employment are often highlighted as examples of how the system exploits workers.

I certainly can see an argument that PE/VC owned tele health has excessive corporate power that prioritizes profit over human welfare. That healthcare has been commodified, and that workers are being exploited (although I still feel there is a tremendous amount of personal agency those NPs should be taking, I can at least comprehend getting out of school and feeling a need to get a job in a tough market).

I don't think late-stage capitalism is the only reason amphetamines are exploding in prescriptions, there are obviously others as well, but I would want to hear more about why those things aren't part of the story.

I think the biggest issue is that invoking that has the ability to 'explain too much' as it were. Like, there is no obvious mechanistic reason why increased seeking of ADHD diagnosed in particular falls out of what you are describing (as opposed to thousands of other possible outcomes). It has a tremendous capacity to become a just-so story that is not substantively different from waving vaguely in the direction of 'modernity'.

Blaming it on a broad conception of the entire material basis of society is also unhelpful in that it does not offer options for trying to address it apart from reorganizing the entire material basis of society. Is that really a lift we can expect from individual clinical practitioners or even medicine as a whole?

 

[sloh]

Maybe it’s not late stage capitalism but just that society is becoming more and more cognitively complex and the baseline IQ and conscientiousness needed to just tread water, much less thrive, keeps getting ratcheted upwards?

 

[R. Matey]

I think more awareness via social media might be drive more people to the office, but it's a very debatable point whether people suffered in silence under different monikers (e.g., "ditzy", "dumb", "blond", "head in the clouds", "space cadet", "airhead", "scattered brain", "Absent minded") or the promise of performance enhancing drugs results in an significant uptick in malingering. My guess that likely both are true. ADHD as a category is catching wind similar to how multiple personality disorder or pediatric bipolar did in past eras likely due in part to the neurodivergence movement and the availability of social media. That makes my job harder because malingers don't like being told no (I've had a few yellers, but mostly people storm out), but it's also been a catalyst to some folks to who actually ADHD to finally get care or for others to get clarity on what's going on with them. All of that is separate from online pill mills, which do harm to patients and should be illegal.

 

[Orgone]

It's often the patients who present with something else who actually have undiagnosed ADHD.

One of my all-time most satisfying private practice cases was someone who presented for anxiety and depression, was struggling with a new promotion to managerial-type duties, and ended up demonstrating various ADHD-type behaviors in treatment (favorite was when she showed up an hour early to an appointment by mistake, then went shopping to kill time and missed her actual appointment because she got distracted in the Target).

Started a low dose long-acting stimulant and her entire life changed.

On the flip side, I've been conned by an ADHD malingerer who became psychotic on her meds and required inpatient hospitalization (not for the first time, as I later found out). IMO the risks of stimulants are not sufficiently appreciated, and I'm convinced that many, many more people than are realized experience more subtle but still pernicious side effects (irritability, personality change).

 

[Liquid8]

One pattern I see in people who do have ADHD is a degree of aversion to medications. They dislike needing to take a medication or taking medication consistently, they want to be less reliant on medication (especially because they worry about forgetting to take meds). They often ask (or like the idea of) not taking medications (or taking less) on less cognitively demanding days. They tend to be quite enthusiastic about the idea of non-controlled options because they are more convenient to be on. Not a diagnostic pattern by any means, but I find it does help to differentiate people seeking treatment from people who want amphetamines.

I’ve often seen the same thing. Most of my patients like the idea of only using medication Monday to Friday, weekend off style arrangements. They don’t use all of what they have been prescribed and often have repeat scripts unfilled, which is fine in my book. In contrast the ones I flag as potential misusers have a pattern of getting their scripts dispensed early and consistently report “running out” before the next appointment, which in my practice should never happen as I calculate the amounts prescribed to fit between appointments.

Eg. here dex comes in packs of 100, so if someone is on 6/day I’d write it for 200 which should last just over a month if taken every day. So if I wrote a script for 6 months, and I get a call at 4 months that the patient has run out I know they’ve gone through 1200 in 4 months or 10/day.

Then I check the database and find that they have gone to different pharmacies or picked up a new script early every time. Once I see something suspicious I tighten things up considerably. Exact quantities for the month only – so 180 instead of 200, 30 day dispensing interval, no early pickups, single pharmacy only etc. If they’re not happy with that, they can go and see someone else.

Locally there are a few psychiatrists who prescribe what can best be described as “heroic” doses of medication (eg. Ritalin 160mg+/day, Vyvanse 210mg), as well as throwing in non-stimulants, but also things like lamotrigine, reboxetine and dementia drugs like memantine – reportedly all in the first consultation. Most are proponents of rapid titration – eg. increasing Vyvanse by 10mg every day until the patient feels something, which I still find bizarre and completely illogical.

Now a lot of these guys are extremely passionate about ADHD, and some work with a lot of forensic and substance use patients. Most have also run into issues with our national medical regulatory authority over prescribing practices. There's probably some kind of saviour complex going on too. But it did make me wonder – if you’re having to consistently resort to prescribing megadoses or offlable stuff (which many of us never have to) is it actually ADHD?

It's often the patients who present with something else who actually have undiagnosed ADHD.

Can remember seeing a young lady with bipolar – put her on lithium immediately as she presented in the most obvious floridly manic state, and things improved quite quickly. Six months on she’s stable, life is good and she has just re-enrolled in a university course. But she’s having a lot of problems there that are very suggestive of untreated ADHD. I remember her being visibly horrified by the suggestion and not wanting another diagnosis or more medication.

 

[Atreides]

I'm not a fan of the M-F and PRN dosing of stimulants. I was trained specifically against this and my clinical experience supports that. People who "don't like" stimulants and want occasional stimulant use tend to be ones with questionable ADHD diagnoses. By definition, ADHD manifests itself and causes impairment in multiple domains. It makes no sense to then prescribe ADHD medication only during work hours or when someone is trying to get extra work then. That smells more of performance enhancement than ADHD.

I know there's a trend to downplay the morbidity and mortality of ADHD but the data is certainly out there. And that morbidity and mortality is not occurring Monday to Friday from 9am to 4pm. It's coming from increased fatal car accidents, it's missing doctor's appointments, it's relationships withering away, it's lack of exercise, it's eating junk food, etc.

I'm not sure what a "less cognitive demanding day" is, but if someone only has ADHD when sitting at a desk at work for 8 hours but not when they get home or on weekends, I strongly question whether they truly have impairment in multiple domains.

 

[Ceke2002]

I'm not a fan of the M-F and PRN dosing of stimulants. I was trained specifically against this and my clinical experience supports that. People who "don't like" stimulants and want occasional stimulant use tend to be ones with questionable ADHD diagnoses. By definition, ADHD manifests itself and causes impairment in multiple domains. It makes no sense to then prescribe ADHD medication only during work hours or when someone is trying to get extra work then. That smells more of performance enhancement than ADHD.

I know there's a trend to downplay the morbidity and mortality of ADHD but the data is certainly out there. And that morbidity and mortality is not occurring Monday to Friday from 9am to 4pm. It's coming from increased fatal car accidents, it's missing doctor's appointments, it's relationships withering away, it's lack of exercise, it's eating junk food, etc.

I'm not sure what a "less cognitive demanding day" is, but if someone only has ADHD when sitting at a desk at work for 8 hours but not when they get home or on weekends, I strongly question whether they truly have impairment in multiple domains.

I agree with what you're saying, but as someone with a diagnosis of ADHD (who doesn't take meds) I can also see the benefit in having medication available PRN. Basically I tried medication (dexamphetamine), it worked really well, but I ended up not liking the side effects so I stopped taking it and decided to manage my ADHD symptoms through non medical means ( by kind of learning to accept and work with it rather than nuking the symptoms with medication). So despite a bit of 'organised chaos' and perhaps taking the scenic route through certain tasks, I'm pretty stable with my most of my ADHD symptoms, plus I've learnt when I need to hand stuff over to someone else as well (so I don't drive, husband takes care of bill payments and most of the financial side).

Now all of that is not to say that there aren't days when I do think I would benefit from having something like dexamphetamine on hand as a PRN option. Managing ADHD sans medication takes a certain amount of brain power/energy each day; if I don't have access to that amount of brain power/energy on any given day (sickness, pain, tiredness, stress levels, that sort of thing) then things don't go that well. Those are the days I will think to myself, "A small amount of dexamphetamine would be really helpful right about now". Mind you I don't think that to the point where I can be bothered to go and get yet another diagnostic test in order to be told what I've already known for the past 50* or so years, just so I can maybe get access to PRN meds. But yeah I do also understand how people who do use medication that way would find it helpful.

(*I was first diagnosed in the mid 70s with ye olde time 'hyperkinetic reaction of childhood' so I've lived with the condition/disorder/syndrome/whatever you wish to term it for a pretty long time).

And as always, I am not a professional just someone with lived experience, this is anecdotal discussions/evidence offerings only, feel free to take on board or disregard as much as you see fit.

 

[clozareal]

I know there's a trend to downplay the morbidity and mortality of ADHD but the data is certainly out there. And that morbidity and mortality is not occurring Monday to Friday from 9am to 4pm. It's coming from increased fatal car accidents, it's missing doctor's appointments, it's relationships withering away, it's lack of exercise, it's eating junk food, etc.

Don't forget about suicide. Those with ADHD have a much lower life expectancy due to suicide and motor vehicle accidents. Impulsivity plus depression places them at higher risk.

 

[DoubtfulDoc]

I'll need to find it. I forget exactly where i read it. Was it from here? or here?

I’ll throw this one in here by Sibley of the MTA study for some additional context that’s helped me with my perspective on adult ADHD diagnosis.

Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD - PubMed

The MTA findings challenge the notion that approximately 50% of children with ADHD outgrow the disorder by adulthood. Most cases demonstrated fluctuating symptoms between childhood and young adulthood. Although intermittent periods of remission can be expected in most cases, 90% of children with...

pubmed.ncbi.nlm.nih.gov

“The study findings emphasize that childhood-onset ADHD is a chronic but waxing and waning disorder with periods of full remission that are more often temporary than sustained. The results support a more informed perspective on ADHD, its impairment, and its tendency to fluctuate over time in symptoms and impairment, perhaps in response to environmental or health-related factors. Providers should expect recurrence of clinically elevated ADHD symptoms and impairments in most patients who experience remission; continued periodic screening for recurrent symptoms and impairments should therefore be standard practice after successful treatment.”

Seems like only 9.1% of the MTA sample obtained sustained recovery after childhood. The majority of everyone else fluctuated quite a bit to varying degrees. I think this highlights the long look needed for assessment. Just asking how work is going now and how relationships are now or recently may miss a lot.

 

[FlowRate]

I’ll throw this one in here by Sibley of the MTA study for some additional context that’s helped me with my perspective on adult ADHD diagnosis.

Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD - PubMed

The MTA findings challenge the notion that approximately 50% of children with ADHD outgrow the disorder by adulthood. Most cases demonstrated fluctuating symptoms between childhood and young adulthood. Although intermittent periods of remission can be expected in most cases, 90% of children with...

pubmed.ncbi.nlm.nih.gov

“The study findings emphasize that childhood-onset ADHD is a chronic but waxing and waning disorder with periods of full remission that are more often temporary than sustained. The results support a more informed perspective on ADHD, its impairment, and its tendency to fluctuate over time in symptoms and impairment, perhaps in response to environmental or health-related factors. Providers should expect recurrence of clinically elevated ADHD symptoms and impairments in most patients who experience remission; continued periodic screening for recurrent symptoms and impairments should therefore be standard practice after successful treatment.”

Seems like only 9.1% of the MTA sample obtained sustained recovery after childhood. The majority of everyone else fluctuated quite a bit to varying degrees. I think this highlights the long look needed for assessment. Just asking how work is going now and how relationships are now or recently may miss a lot.

It's too bad the MTA stopped tracking the cohort when mean age was 25. Would have been an interesting, if indirect, way of testing the late-frontal lobe development hypothesis to see if prevalence persists into the early 30's. (Given normal frontal lobe myelination happens in the mid 20's and may happen in late 20's for ADHD.)

 

[Ceke2002]

Like most outpatient psychiatrists, I'm getting a huge uptick in ADHD eval requests. I used to have an excellent psychologist colleague who would do pretty comprehensive evaluations but she's gone now. I had pretty minimal ADHD training during residency (years ago) but have done plenty of self-study since then. I'm very comfortable with managing ADHD but the diagnostic part is much more challenging for me. I've tried the DIVA and ACE Plus that I've seen recommended here but feel I'm either "Feeding the answer" to the patient with the way I ask questions or am asking questions in such a veiled manner that it fails to elicit the relevant information.

Anyone have any recommendations for training or even recorded interviews of expert clinicians evaluating for ADHD? I honestly considered following some of my colleagues who just say "You need to have a psychological evaluation from a PhD psychologist before I'll treat your ADHD" but the quality of psychologists in my area is so poor that I wouldn't trust an ADHD diagnosis from most of them anyway.

I found this childhood ADHD assessment example from UT Health San Antonio. that might be helpful? Someone correct me if I'm wrong but I've always thought of childhood and adult ADHD assessments as essentially being kind of the same - get as much collateral where possible, structured interview, observing the patient's behaviour, etc, etc.

Most of what is available in clinical vignettes is centred around childhood assessments of ADHD, or at least what I can access is.

 

[R. Matey]

I’ll throw this one in here by Sibley of the MTA study for some additional context that’s helped me with my perspective on adult ADHD diagnosis.

Worth mentioning that variability depends deeply on measurement of ADHD. Specifically whether you view 1-2 symptom changes as (1) measurement error or (2) meaningful symptom change. People at the NIH found different rates of change in three datasets.

 

[calvnandhobbs68]

I found this childhood ADHD assessment example from UT Health San Antonio. that might be helpful? Someone correct me if I'm wrong but I've always thought of childhood and adult ADHD assessments as essentially being kind of the same - get as much collateral where possible, structured interview, observing the patient's behaviour, etc, etc.

Most of what is available in clinical vignettes is centred around childhood assessments of ADHD, or at least what I can access is.

I absolutely do not view them as the same at all.

For one assessment (childhood) you are getting a real time assessment of current and relatively recently (often within the past <5 years) past symptoms using multiple usually fairly good quality collateral sources using information/scales which have been standarized using those same sources. So for instance, Conners have been standardized on cohorts of 6-18yo for all self, parent and teacher reports in yearly increments for both male and female cohorts. Also, the vast majority of information we have about presentation, assessment, treatment and outcomes of ADHD is from children, so the quality and amount of data for all these areas is just higher overall.

For adults, the assessments are wayyy "dirtier" (as in lower quality assessments, evidence, data, etc). Your collateral is often much poorer quality especially around historical symptoms (trying to recall symptoms from 10+ years ago) or not available. Your overall assessment is often complicated by years of other complicating medical or psychiatric conditions which can mimic EF difficulties. You have much more of a real concern around performance enhancement or diversion and the recognition that this diagnosis opens up the ability almost automatically to get highly controlled medications. There is much more of a concern around overreporting or attempting to game more standardized scales and lack of overall high quality standardization of these scales. These days there's also the recognition that "ADHD" has become a catch all and fall-back that a lot of adults are looking for to explain various symptoms (again around the incentive for diagnosis).

Also, I'm surprised that kid could even hold it together for that video...show me another 8yo who'd stay perfectly still and not be super bored with that lol. That video isn't super helpful. The guy literally just read off ADHD criteria with very little followup about "give me examples of what you mean by that". It looks like its some kind of standardized patient thing though because her answers were super canned and rote.

Clinical interview/behavioral observation with the child is notoriously unreliable for ADHD in that, if it's "positive" (I'm seeing a lot of problems I feel are consistent with ADHD) that's helpful but there are plenty of kids who hold it together in the office and are a mess at home and school...this is a very well recognized phenomenon. Asking kids about if they're getting in trouble at school or whatever is also only marginally helpful. They'll say "no" like 90 percent of the time.

 

[Ceke2002]

I absolutely do not view them as the same at all.

For one assessment (childhood) you are getting a real time assessment of current and relatively recently (often within the past <5 years) past symptoms using multiple usually fairly good quality collateral sources using information/scales which have been standarized using those same sources. So for instance, Conners have been standardized on cohorts of 6-18yo for all self, parent and teacher reports in yearly increments for both male and female cohorts. Also, the vast majority of information we have about presentation, assessment, treatment and outcomes of ADHD is from children, so the quality and amount of data for all these areas is just higher overall.

For adults, the assessments are wayyy "dirtier" (as in lower quality assessments, evidence, data, etc). Your collateral is often much poorer quality especially around historical symptoms (trying to recall symptoms from 10+ years ago) or not available. Your overall assessment is often complicated by years of other complicating medical or psychiatric conditions which can mimic EF difficulties. You have much more of a real concern around performance enhancement or diversion and the recognition that this diagnosis opens up the ability almost automatically to get highly controlled medications. There is much more of a concern around overreporting or attempting to game more standardized scales and lack of overall high quality standardization of these scales. These days there's also the recognition that "ADHD" has become a catch all and fall-back that a lot of adults are looking for to explain various symptoms (again around the incentive for diagnosis).

Also, I'm surprised that kid could even hold it together for that video...show me another 8yo who'd stay perfectly still and not be super bored with that lol. That video isn't super helpful. The guy literally just read off ADHD criteria with very little followup about "give me examples of what you mean by that". It looks like its some kind of standardized patient thing though because her answers were super canned and rote.

Clinical interview/behavioral observation with the child is notoriously unreliable for ADHD in that, if it's "positive" (I'm seeing a lot of problems I feel are consistent with ADHD) that's helpful but there are plenty of kids who hold it together in the office and are a mess at home and school...this is a very well recognized phenomenon. Asking kids about if they're getting in trouble at school or whatever is also only marginally helpful. They'll say "no" like 90 percent of the time.

Thank you so very much for the correction on the information here, seriously I mean it. I don't actually remember all that much of my own assessment in childhood (it was 1975, I was around 3 years old), just mostly a few images and impressions, plus what I was told by family later on. Obviously the diagnosis then was Hyperkinetic Reaction of Childhood. When I was re-assessed as an adult in 1999 it seemed like the assessment was really thorough, more so than I was probably expecting it to be. Structured interview, ASRS, another assessment tool I'm drawing a blank on at the moment (tis 4.40 am here, sorry brain not entirely braining); sleep studies, brain scan, lots of ruling out other possible causes of symptoms; whatever collateral I could provide (school reports mostly). I guess I just assumed that if a Doctor is assessing for ADHD in adulthood that they're all tending to do their due diligence, with a few bad apple exceptions. Getting assessed for ADHD in adulthood, for me at least, felt like being expected to jump through several hoops and perform a three ring circus before getting a diagnosis. I shouldn't have assumed that that's the norm for everyone. Thank you again for the correction and additional information; I hope it ends up also being of some help/use to the OP.

 

[oliversacks4thewin]

I found this childhood ADHD assessment example from UT Health San Antonio. that might be helpful? Someone correct me if I'm wrong but I've always thought of childhood and adult ADHD assessments as essentially being kind of the same - get as much collateral where possible, structured interview, observing the patient's behaviour, etc, etc.

Most of what is available in clinical vignettes is centred around childhood assessments of ADHD, or at least what I can access is.

While I appreciate the sentiment of the training video, I cannot help but recognize that the provider is just going down the line on the Vanderbilt-Parent form, with simple yes/no questions and the Vanderbilt is specifically designed to assess the frequency with which symptoms occur. Scores of occasional (coded as "1" on the Vanderbilt) are not considered contributory to the elevation of symptoms of ADHD for either inattention and/or hyperactivity. Of note too, is the child's own endorsement of no observed difficulty with concentration on the depression/anxiety screening, which is in stark contrast to the report of ADHD symptoms. How do we reconcile this in a child presentation and much less, extrapolate to the endorsement of an adult recalling past history? More critically, how can this provider determine that Sam meets criteria for ADHD, when the diagnosis per the DSM-5-TR requires present dysfunction across two distinct settings, which is why we administer a paired Teacher form. This is all to just highlight just how difficult the diagnosis is to make even in a child but even more so with an adult, and the assessment cannot be viewed in the same manner. It's tricky stuff for sure.

 

[DoubtfulDoc]

Worth mentioning that variability depends deeply on measurement of ADHD. Specifically whether you view 1-2 symptom changes as (1) measurement error or (2) meaningful symptom change. People at the NIH found different rates of change in three datasets.

Great article, thank you for sharing