Evaluating for ADHD?

[R. Matey]

Yea, I could see that I suppose with mixing up known deficits with ability to detect on a specific instrument.

I mean CPTs may detect lower levels of response inhibition in some with ADHD, but it wouldn't be diagnostic because a person could still be symptomatic and perform just fine. They could be predominately hyperactive-impulsive or have enough intellectual horsepower to rally for that specific task performance, for instance. That doesn't mean they still don't lose their keys four times of week or spend three hours at work researching the mating behavior of whales while the TPS reports remain overdue.

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[clozareal]

Oh yeah, I’ve heard of those too. I believe it’s another CPT, I don’t see why it would be any better or different. However, I have not explicitly looked at whether or not there is good research on its use.

It has a camera that objectively measures for movement for hyperactivity which CPT does not have.

 

[comp1]

What exactly do all of these tests do emotionally for you as a provider? It must be something big. Are you all subjecting people reporting depression to this? Do an H&P and treat the patient. Honestly....

 

[psydocc]

What exactly do all of these tests do emotionally for you as a provider? It must be something big. Are you all subjecting people reporting depression to this? Do an H&P and treat the patient. Honestly....

I like having as much data as possible before putting someone on a daily schedule 2 drug. There's a big difference between someone coming in for depression and willing to start on an antidepressant vs someone coming in declaring they have ADHD (diagnosed by tiktok) and demanding amphetamines.

 

[splik]

What exactly do all of these tests do emotionally for you as a provider? It must be something big. Are you all subjecting people reporting depression to this? Do an H&P and treat the patient. Honestly....

As many as half of adults presenting for ADHD evaluation are malingering, and as many as 1 in 3 young people divert stimulants. 75% of those who think they have adult ADHD do not have ADHD. Presenting a false equivalency between depression and ADHD does not erase these reality\ies. Of course, there are other reasons for all this discussion of ADHD evaluation, including the lack of training many psychiatrists have in the assessment and treatment of adults with ADHD, and the moral panic and rationing of controlled substances. Some people also have an irrational fear of being ensnared in a DEA investigation. Things like the QBtest or indiscriminate neuropsych testing exploit clinician insecurities regarding diagnosing ADHD, but there are also legitimate concerns regarding accurate diagnosis given high rates of people without ADHD seeking diagnosis, high rates of malingering, high rates of diversion and abuse. None of this applies to people reporting depression.

 

[comp1]

Legitimate concerns about diversion and malingering don't justify these tests. The patient can still malinger on the test and they can still divert after getting your Rx. My point is that this is about prescriber anxiety, not ultimate clinical utility or any sort of patient benefit. It's like getting a chest CT for a cough. Given the wait time for neuropsychologists, I'd really rather they were doing something other than treating the worries of MDs by proxy. And patients definitely malinger depression all the time. It may be more of a Youtube than TikTok thing, but it is done for lots of reasons and could be more financially valuable than a monthly Adderall prescription depending on the setting.

 

[oliversacks4thewin]

As many as half of adults presenting for ADHD evaluation are malingering, and as many as 1 in 3 young people divert stimulants. 75% of those who think they have adult ADHD do not have ADHD. Presenting a false equivalency between depression and ADHD does not erase these reality\ies. Of course, there are other reasons for all this discussion of ADHD evaluation, including the lack of training many psychiatrists have in the assessment and treatment of adults with ADHD, and the moral panic and rationing of controlled substances. Some people also have an irrational fear of being ensnared in a DEA investigation. Things like the QBtest or indiscriminate neuropsych testing exploit clinician insecurities regarding diagnosing ADHD, but there are also legitimate concerns regarding accurate diagnosis given high rates of people without ADHD seeking diagnosis, high rates of malingering, high rates of diversion and abuse. None of this applies to people reporting depression.

Please do not misconstrue this as antagonism, but I am genuinely curious about the numbers you reported in first two statements. Can you provide the literature around this, as I would love to review it myself.

 

[Merovinge]

Legitimate concerns about diversion and malingering don't justify these tests. The patient can still malinger on the test and they can still divert after getting your Rx. My point is that this is about prescriber anxiety, not ultimate clinical utility or any sort of patient benefit. It's like getting a chest CT for a cough. Given the wait time for neuropsychologists, I'd really rather they were doing something other than treating the worries of MDs by proxy. And patients definitely malinger depression all the time. It may be more of a Youtube than TikTok thing, but it is done for lots of reasons and could be more financially valuable than a monthly Adderall prescription depending on the setting.

That would depend on how it's managed. If a psychiatrist is approving medical leave for someone based on 1 office visit and letting the patient stay at home all day than sure that might be the case. Most docs I know are pretty insistent on someone being in a PHP/IOP if they are on med leave which greatly reduces any primary gain for depression. It is also almost impossible to malinger depression 30 hours a week surrounded by therapists and psychiatrists.

 

[WisNeuro]

A new neuropsychologist to our site, they’re about 1 year post fellowship, was excited because we are able to get a Connors CPT up and running. They notes how helpful it would be for our adult ADHD evals. I was pretty confident that CPTs are not helpful for accurately discriminating between those that do and do not have ADHD. Definitely not as a stand alone measure and even in a bigger battery, it has questionable utility. Neuropsychology peers, do I have it wrong? Here are some of the citations that have stood out to me in the past below, but there are more certainly about other instruments, like the DIVAs performance when compared to other CPTs and how it’s more sensitive.

Baggio, S., Hasler, R., Giacomini, V., El-Masri, H., Weibel, S., Perroud, N., & Deiber, M.-P. (2019). Does the Continuous Performance Test Predict ADHD Symptoms Severity and ADHD Presentation in Adults? Journal of Attention Disorders, 24(6), 840-848. https://doi.org/10.1177/1087054718822060 (Original work published 2020)

Callan, P. D., Swanberg, S., Weber, S. K., Eidnes, K., Pope, T. M., & Shepler, D. (2024). Diagnostic Utility of Conners Continuous Performance Test-3 for Attention Deficit/Hyperactivity Disorder: A Systematic Review. Journal of Attention Disorders, 28(6), 992-1007. https://doi.org/10.1177/10870547231223727 (Original work published 2024)

@WisNeuro, not sure if you’re on this thread. Would appreciate your feedback.

CPTs/IVAs/etc are pretty garbage instruments in general. Moreso in ADHD evaluations. The new neuropsychologist at your site does not seem very knowledgeable of the area, unfortunately.

It has a camera that objectively measures for movement for hyperactivity which CPT does not have.

What is the sensitivity and specificity of this variable, given that "fidgeting" during long periods of sitting still is pretty high in the general population. I've seen some prelim data from the QB test and was deeply unimpressed. I'd love to see the data they are basing this specific piece on. We did a lot of eye tracking and movement work in my psychophysiology lab, and it's notoriously messy and hardly ever replicates. I suspect they did an extreme groups comparison and called it a day.

 

[calvnandhobbs68]

What exactly do all of these tests do emotionally for you as a provider? It must be something big. Are you all subjecting people reporting depression to this? Do an H&P and treat the patient. Honestly....

Are you stating that MDD and ADHD are equivalent in the types of disorders they are? If so, I'd highly encourage you crack open DSM 5 and figure out the difference between a neurodevelopmental disorder and mood disorder.

I certainly subject patients to standardized evaluations and gather additional collateral if at all possible for other neurodevelopmental disorders, for instance IQ and adaptive functioning evaluations for suspected intellectual disability or standardized ASD evaluations for suspected autism spectrum disorder.

 

[Ceke2002]

CPTs/IVAs/etc are pretty garbage instruments in general. Moreso in ADHD evaluations. The new neuropsychologist at your site does not seem very knowledgeable of the area, unfortunately.



What is the sensitivity and specificity of this variable, given that "fidgeting" during long periods of sitting still is pretty high in the general population. I've seen some prelim data from the QB test and was deeply unimpressed. I'd love to see the data they are basing this specific piece on. We did a lot of eye tracking and movement work in my psychophysiology lab, and it's notoriously messy and hardly ever replicates. I suspect they did an extreme groups comparison and called it a day.

I just tried one of the demo ones online (the one where you hit the spacebar on every number except 3).

So I tried to follow the instructions for all of 30 seconds, but every time I focused in on the screen to see the numbers come up I forgot to hit the space bar, so then I just decided to try rapid fire hitting the space bar on repeat (not realising it stops the test if you hit on a wrong number), so back to actually trying to focus and still then forgetting to hit the space bar when I was meant to, so I decided to just start drumming random beats on my space bar, which somehow lead me to getting Emerson Lake and Palmer 'Fanfare for the Common Man' stuck in my head and space bar drumming a rhythm to that, which actually worked for a while so I figured I'd finally cracked it, but no, and then about 3 minutes in I was soooo bored I started tapping out 'La Cucaracha' whilst giggling like an idiot.

I think I failed the test. 🤔

(edited to add: Sorry I should have made it clearer that having done some demo tests of these types of computer assessments, I find it hard to see the point of them, just my opinion as a layperson).

 

[docloufan]

CPTs are garbage for several reasons...but mostly bc they don't assess any of the actual established DSM criteria of ADHD. Literally none.

How it got so popular is purely bc some health professionals want "evidence" to support the presence of a diagnosis that is vague and whose symptoms and impairments can be waxing and waning over time. I don't know how anyone who bothers to dig into this disorder's history and these instruments can come to another reasonable conclusion other than this.

 

[Ceke2002]

CPTs are garbage for several reasons...but mostly bc they don't assess any of the actual established DSM criteria of ADHD. Literally none.

How it got so popular is purely bc some health professionals want "evidence" to support the presence of a diagnosis that is vague and whose symptoms and impairments can be waxing and waning over time. I don't know how anyone who bothers to dig into this disorder's history and these instruments can come to another reasonable conclusion other than this.

Yeah, this is what I meant when I said I didn't understand what the point of them was. I mean my poor performance on a demo version could have been attributed to any number of things besides a diagnosis of ADHD. What if I was sleep deprived, or felt unwell, or was in pain, or any number of non ADHD reasons for not being able to focus. If I took that test again on a different day, or even a different time of the day I'd probably do well enough to not show any 'signs' (according to the test) of ADHD, and yet I already have a bonafide diagnosis several times over, without the need to play a computer game that can't tell between ADHD focus issues and any number of other things. It does just seem a little disingenuous to me, like rather than learn how to do a proper interview and assessment you just have someone play a game.

 

[comp1]

The point of the tests is to reduce the anxiety of the person ordering it through some sort of medicolegal fantasy that when the DEA busts down their door they can wave these test results in front of them to be spared.