Evaluating for ADHD?

[R. Matey]

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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.

 

[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.

 

[Chromium Surfer]

Hello everyone, been really fascinating reading through these perspectives and seeing various thoughts about ADHD and adult ADHD. I wanted to share a brief summary overview de-identified story/case I have been following as it pertains to an adult ADHD diagnosis and would appreciate hearing your thoughts.

• Initial presentation
  • Lifelong high achiever, no childhood MH diagnoses, mid to late 30’s male
  • In medical school develops persistent concentration/attention/organization issues leading to academic challenges, diagnosed with adjustment disorder and starts antidepressant tx but cognitive issues persist.
  • Seeks out ADHD eval to understand basis of persistent cognitive issues. First psychologist (diagnostic interview only) rules out ADHD, citing prior academic/life success, ADHD being a developmental disorder and lack of ADHD history, confounding from adjustment-disorder diagnosis, difficulty of medical school leading to cognitive challenges etc.
• Ongoing struggles
  • Cognitive issue continue; academic struggles persist
  • 1+ year later, second psychologist contacts student from waitlist and performs full neuropsych evaluation: cross-battery including some parts of WAIS-IV plus targeted tests of working memory, processing speed, learning/memory, executive function,[core domain] and multiple behavioral rating scales completed by student and their spouse
• Key findings
  • Wide scatter: WAIS-IV subtests from low-average to very superior.
  • Core domains show scores from <1st to >70th percentile, with relative weaknesses in every domain tested.
  • Behavior rating scales by patient and spouse in the clinically significant ADHD range.
• Outcome
  • Diagnosed with moderate–severe ADHD, predominantly inattentive.

Would love to hear all thoughts, ranging from general thoughts, speculations about causes for late diagnosis, what you would have done anything different, etc. If possible not quoting this reply would be optimal but I think it's de-identified enough that it wont matter either way. Thanks for reading and looking forward to seeing your replies

 

[WisNeuro]

Did second psychologist do any PVT/SVT testing? That profile is very suspect with someone at that level of academic achievement. Not impossible, would just be very atypical. Also, even with high performance in K-12, they would still have to have symptoms of some kind developmentally. Very bright kids with ADHD can still succeed, but they still have symptoms.

 

[calvnandhobbs68]

Would love to hear all thoughts, ranging from general thoughts, speculations about causes for late diagnosis, what you would have done anything different, etc. If possible not quoting this reply would be optimal but I think it's de-identified enough that it wont matter either way. Thanks for reading and looking forward to seeing your replies

A "case you've been following" that's definitely not you or someone you know personally?

Here's one of the key issues here:
"In medical school develops persistent concentration/attention/organization issues leading to academic challenges"

You don't "develop" EF deficits with ADHD in your 20s/30s. What you are stating with an adult diagnosis of ADHD is that the deficits were present but were missed somehow along the way and there should be evidence of that. People can have problems with concentrating or achieving high level academic standards (ex. medical school, law school, PhD programs, etc) without having what we would classify currently as ADHD.

Also yeah there's relative weakness in every tested domain but this person was somehow able to get into medical school without this being a concern whatsoever until med school? I'm no neuropsychologist of course but yes where's the validity testing? And where is the collateral and history that would make them think this was ADHD?

Edit: Also, moderate-severe ADHD that wasn’t diagnosed until med school. Bud my severe ADHD cases are kids that are getting kicked out of school and have IEPs by the time they’re in 1st grade. Sounds like this psychologist doesn’t really understand rating severity either….like the one who “diagnosed” a teenager I saw with ASD as Level 2.

 

[oliversacks4thewin]

Hello everyone, been really fascinating reading through these perspectives and seeing various thoughts about ADHD and adult ADHD. I wanted to share a brief summary overview de-identified story/case I have been following as it pertains to an adult ADHD diagnosis and would appreciate hearing your thoughts.

• Initial presentation
  • Lifelong high achiever, no childhood MH diagnoses, mid to late 30’s male
  • In medical school develops persistent concentration/attention/organization issues leading to academic challenges, diagnosed with adjustment disorder and starts antidepressant tx but cognitive issues persist.
  • Seeks out ADHD eval to understand basis of persistent cognitive issues. First psychologist (diagnostic interview only) rules out ADHD, citing prior academic/life success, ADHD being a developmental disorder and lack of ADHD history, confounding from adjustment-disorder diagnosis, difficulty of medical school leading to cognitive challenges etc.
• Ongoing struggles
  • Cognitive issue continue; academic struggles persist
  • 1+ year later, second psychologist contacts student from waitlist and performs full neuropsych evaluation: cross-battery including some parts of WAIS-IV plus targeted tests of working memory, processing speed, learning/memory, executive function,[core domain] and multiple behavioral rating scales completed by student and their spouse
• Key findings
  • Wide scatter: WAIS-IV subtests from low-average to very superior.
  • Core domains show scores from <1st to >70th percentile, with relative weaknesses in every domain tested.
  • Behavior rating scales by patient and spouse in the clinically significant ADHD range.
• Outcome
  • Diagnosed with moderate–severe ADHD, predominantly inattentive.

Would love to hear all thoughts, ranging from general thoughts, speculations about causes for late diagnosis, what you would have done anything different, etc. If possible not quoting this reply would be optimal but I think it's de-identified enough that it wont matter either way. Thanks for reading and looking forward to seeing your replies

I agree with both previous posters but just wanted to inquire further about these "multiple behavioral rating scales." Which ones? What was the validity and reliability (e.g., potential for overreporting) scales on these? How do they demonstrate "clinically significant ADHD range" for an adult patient?

 

[R. Matey]

And where is the collateral and history that would make them think this was ADHD?

This was my question. It's not like their partner is a dispassionate rater here. I also want to know if the impairment is cross-situational or simply med school plus stress of med school on social life.

 

[Chromium Surfer]

I will try to respond to all comments here but please let me know if I missed anything. Also to clarify when I said "case I have been following" I did not mean to imply that I did not have a personal connection, as I certainly do have a personal/familial connection to them! I de identifed to protect privacy but they are aware of and fine with me discussing this. Also full disclosure I am coming at this as a partial layman since I am still just a medical student and do not plan on going into psych though I do find the field to be interesting!

Did second psychologist do any PVT/SVT testing? That profile is very suspect with someone at that level of academic achievement. Not impossible, would just be very atypical. Also, even with high performance in K-12, they would still have to have symptoms of some kind developmentally. Very bright kids with ADHD can still succeed, but they still have symptoms.

Thanks for your reply! I was allowed to read the eval report and there was a line that said "performance validity testing on embedded measures indicates that he produced a valid profile". Is this what you were referring to when you say "PVT"? I am not sure what specific PVT's were used so this is all I can say about that, sorry if my comment is unhelpful. The diagnosis came as a a shock to us all because like you said they had high performance in K-12 and were not flagged with behavioral issues. The diagnosis led to further digging through old files by their nuclear family and led to some more hilarious discoveries. Old report cards mentioned behavioral issues like extreme difficulty listening to/following directions in class, completing assignments but forgetting to turn them in, rushing through assignments, and multiple comments about the need to think before acting. Mixed between these comments were more positive comments about them being good at reading/math when applying themselves ec. But all of these report cards were all for K-5th grade, and for most of their academic life prior to med school they were seen as a mild mannered good kid. I guess they did so well adjusting and their individual/parents lack of memory made the rest of us assume there were no earlier signs. Also their family definitely has some stigma associated with mental health stuff because of their religious beliefs.

Apologies if the terminology of masking is crude or wrongly applied but do "bright kids" also have the ability to modulate their behaviors and "mask" sooner than their peers?

A "case you've been following" that's definitely not you or someone you know personally?

Here's one of the key issues here:
"In medical school develops persistent concentration/attention/organization issues leading to academic challenges"

You don't "develop" EF deficits with ADHD in your 20s/30s. What you are stating with an adult diagnosis of ADHD is that the deficits were present but were missed somehow along the way and there should be evidence of that. People can have problems with concentrating or achieving high level academic standards (ex. medical school, law school, PhD programs, etc) without having what we would classify currently as ADHD.

Also yeah there's relative weakness in every tested domain but this person was somehow able to get into medical school without this being a concern whatsoever until med school? I'm no neuropsychologist of course but yes where's the validity testing? And where is the collateral and history that would make them think this was ADHD?

Thanks for your reply, earlier in this comment I provided context regarding connections and maybe also some clarification about further history unbeknownst to them prior to their diagnosis? Also wouldn't the fact that their spouse also completed the behavioral rating scales and shared some of their observations be collateral?

I agree with both previous posters but just wanted to inquire further about these "multiple behavioral rating scales." Which ones? What was the validity and reliability (e.g., potential for overreporting) scales on these? How do they demonstrate "clinically significant ADHD range" for an adult patient?

Thanks for your reply! I believe they completed the Conners, Barkley for adult and childhood symptoms, BRIEF-A and their spouse indolently completed the adult behavior rating scales as well. The clinically significant was in reference to their T scores from the various scales they completed being above a threshold that the psychologist included in their report. Since I am a layman more or less I cant speak to the potential for overrporting unfortunately.

This was my question. I also want to know if the impairment is cross-situational or simply med school plus stress of med school on social life.

Their spouse definitely had some things to say about their "quirks' at home haha. Maybe the quirks were actually something else in retrospect but who knows!


Also as a general comment to everyone the psychologist labeled them as above average to high intelligence but with relative weakness in each of the various areas I mentioned and labeled as core domains(sorry if my terminology was incorrect I was just trying to use a summative term.) The psychologist stated that they felt like this student progressed through school without difficulty because of their cognitive strengths but then coming to med school hit their limits so to speak because of the academic and concurrent life stressors they faced.

 

[Chromium Surfer]

Overall at least based on the initial responses I received, it seems like their experience is highly atypical which at least to me aligns with the collective shock we all had after they shared their diagnosis.

 

[Ceke2002]

Apologies if the terminology of masking is crude or wrongly applied but do "bright kids" also have the ability to modulate their behaviors and "mask" sooner than their peers?

Not a healthcare practitioner of any description, personal anecdote only. I've been diagnosed with ADHD since early childhood, was also labeled as 'gifted' age 7 and attended one of the first gifted children programs in South Australia. 'Masking' in terms of academic performance (up to a point)? Yes. 'Masking' in terms of pretty much anything else symptom wise? A definite no. As I'm sure you already know ADHD affects performance across multiple spheres of life; being considered 'highly intelligent' might have allowed me to 'mask' to a degree in one area, but not across all of them.

 

[R. Matey]

The psychologist stated that they felt like this student progressed through school without difficulty because of their cognitive strengths but then coming to med school hit their limits so to speak because of the academic and concurrent life stressors they faced.

That's an argument for any number of psychiatric disorders. ADHD is not the only mental health disorder that *can* impair executive functioning.

 

[Chromium Surfer]

That's an argument for any number of psychiatric disorders. ADHD is not the only mental health disorder that *can* impair executive functioning.

definitely agree with you there! Im speculating but I am assuming the psychologist mentioned this to provide a partial explanation for why the diagnosis came later in life. But who knows!

 

[WisNeuro]

I will try to respond to all comments here but please let me know if I missed anything. Also to clarify when I said "case I have been following" I did not mean to imply that I did not have a personal connection, as I certainly do have a personal/familial connection to them! I de identifed to protect privacy but they are aware of and fine with me discussing this. Also full disclosure I am coming at this as a partial layman since I am still just a medical student and do not plan on going into psych though I do find the field to be interesting!



Thanks for your reply! I was allowed to read the eval report and there was a line that said "performance validity testing on embedded measures indicates that he produced a valid profile". Is this what you were referring to when you say "PVT"? I am not sure what specific PVT's were used so this is all I can say about that, sorry if my comment is unhelpful. The diagnosis came as a a shock to us all because like you said they had high performance in K-12 and were not flagged with behavioral issues. The diagnosis led to further digging through old files by their nuclear family and led to some more hilarious discoveries. Old report cards mentioned behavioral issues like extreme difficulty listening to/following directions in class, completing assignments but forgetting to turn them in, rushing through assignments, and multiple comments about the need to think before acting. Mixed between these comments were more positive comments about them being good at reading/math when applying themselves ec. But all of these report cards were all for K-5th grade, and for most of their academic life prior to med school they were seen as a mild mannered good kid. I guess they did so well adjusting and their individual/parents lack of memory made the rest of us assume there were no earlier signs. Also their family definitely has some stigma associated with mental health stuff because of their religious beliefs.

Apologies if the terminology of masking is crude or wrongly applied but do "bright kids" also have the ability to modulate their behaviors and "mask" sooner than their peers?



Thanks for your reply, earlier in this comment I provided context regarding connections and maybe also some clarification about further history unbeknownst to them prior to their diagnosis? Also wouldn't the fact that their spouse also completed the behavioral rating scales and shared some of their observations be collateral?

Thanks for your reply! I believe they completed the Conners, Barkley for adult and childhood symptoms, BRIEF-A and their spouse indolently completed the adult behavior rating scales as well. The clinically significant was in reference to their T scores from the various scales they completed being above a threshold that the psychologist included in their report. Since I am a layman more or less I cant speak to the potential for overrporting unfortunately.



Their spouse definitely had some things to say about their "quirks' at home haha. Maybe the quirks were actually something else in retrospect but who knows!


Also as a general comment to everyone the psychologist labeled them as above average to high intelligence but with relative weakness in each of the various areas I mentioned and labeled as core domains(sorry if my terminology was incorrect I was just trying to use a summative term.) The psychologist stated that they felt like this student progressed through school without difficulty because of their cognitive strengths but then coming to med school hit their limits so to speak because of the academic and concurrent life stressors they faced.

Couple things, not all PVTs are created equal. I can give PVTs with poor sensitivity if I want to make sure that I will likely not catch most malingering patients. As for the spouse filling out a report, unless she knew him very well as a child, that isn't as useful as other pieces of info. Bottom line, this sounds much more like something that is not ADHD. My strong suspicion is that the psychologist runs an ADHD mill and nearly everyone who comes in, walks out with a diagnosis and a bunch of accommodations that are not empirically supported.

 

[Chromium Surfer]

Thanks for sharing your input! My understanding was that the spouse independently completed rating scales assessing current functioning and shared their thoughts about his current functioning. Not sure if that counts as collateral. Still good to hear from others their thoughts. I’m hoping to potentially go into primary care and assume I might have to do some triage/screening related to ADHD.

 

[WisNeuro]

Thanks for sharing your input! My understanding was that the spouse independently completed rating scales assessing current functioning and shared their thoughts about his current functioning. Not sure if that counts as collateral. Still good to hear from others their thoughts. I’m hoping to potentially go into primary care and assume I might have to do some triage/screening related to ADHD.

I mean, it is collateral, but due the non-specific nature of many ADHD sx, it doesn't help as much in establishing a diagnosis. It really depends if the psychologist adequately ruled out differentials, along with the patient's medical providers.

 

[R. Matey]

definitely agree with you there! Im speculating but I am assuming the psychologist mentioned this to provide a partial explanation for why the diagnosis came later in life. But who knows!

So, ADHD is a neurodevelopmental disorder meaning that symptoms onset occurs in childhood. DSM criteria is symptoms must be present before age 12. There is very little, if any, credible evidence of adult-onset ADHD. Large datasets of ADHDers find something like <1% of cases onset after 12 years old, but it's usually still around early to middle adolescence and even then it's still a question as to whether those cases are explained by other psychiatric or drug comorbidities. Sounds like this psychologist may be unaware of that fact.

 

[Chromium Surfer]

So, ADHD is a neurodevelopmental disorder meaning that symptoms onset occurs in childhood. DSM criteria is symptoms must be present before age 12. There is very little, if any, credible evidence of adult-onset ADHD. Large datasets of ADHDers find something like <1% of cases onset after 12 years old, but it's usually still around early to middle adolescence and even then it's still a question as to whether those cases are explained by other psychiatric or drug comorbidities. Sounds like this psychologist may be unaware of that fact.

Thanks for providing this additional insight and some numbers related to case onset. I'm not sure if you saw the part of my comment that mentioned old report cards being found that indicated significant behavioral issues that were in K-5th grade. Still I suppose a natural counter to that would be that kids can be misbehaving in K-5 and not have ADHD.

What are your general thoughts about adults who might have had symptoms of ADHD prior to age 12 that were missed due to a variety of factors such as cultural bias, academic prowess causing bad behavior to be overlooked, lack of access to health care at a young age etc. As a likely future primary care provider beyond completing a detailed history and obtaining collateral are there other things in your opinion that I can be aware of/do to help me recognize an adult who does ADHD that was missed or misdiagnosed as something else earlier in their life?

Thanks for your time!

 

[Chromium Surfer]

I mean, it is collateral, but due the non-specific nature of many ADHD sx, it doesn't help as much in establishing a diagnosis. It really depends if the psychologist adequately ruled out differentials, along with the patient's medical providers.

Gotcha makes a ton of sense and I agree that ruling out other differentials is important. I think my cousin completed a GAD and PHQ-9 as part of his assessment but Ive given those before as a med student so that doesn't inspire me to believe. that is sufficient for ruling anxiety and depression out.

Any tips for a future PCP when it comes to managing patients asking about ADHD? I dont want to just refer to psych if I can do something thats actually helpful beforehand you know?

 

[oliversacks4thewin]

Thank you for providing the additional information. Quite interesting that all of this additional collateral was unearthed. I literally have no idea where a single one of my old report cards has ended up lol. In my experience, as a pediatric psychologist, I typically find reports of "severe behavioral concerns such as "extreme difficulty listening to/following directions in class, completing assignments but forgetting to turn them in, rushing through assignments, and multiple comments about the need to think before acting" rarely result in solid grades. Additionally, reflecting on DSM-5-TR criteria ("Section D: There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning") , suggest that if an individual can adapt through these and achieve the grades they did, without context of other problematic behaviors (social issues, impulsivity leading to significant issues, etc.) this is not representative of clinically significant impairment, and therefore not matching diagnostic criteria.

You did not specify which Barkley measures (there is actually quite a few), but I am very confused why you would administer both an adult and childhood measure...as the adult measures already inquires about childhood experiences...

 

[futureapppsy2]

I actually do know a high-achieving physician who was diagnosed with ADHD in their 50s. Despite being high achieving, their profile was textbook ADHD-PI in many ways (goes off on tangents, has to be frequently redirected in conversation, late to almost everything, took an entire sabbatical primarily to mass delete the 1000s and 1000s of unread emails from their inbox, has entire days where they sit in front of the computer and don’t do anything because they keep being distracted by anything and everything, etc) with a long history of seeking assessment/treatment for it because they were chronically distressed by their inability to consistently complete stuff with no one ever making a diagnosis other than “just need a new work style” and recommending behavioral stuff that the patient could never remember to do or plan enough to implement . In this case, I honestly do think them being legitimately genius-level intelligent played into it, as did being in a job where productivity is assessed less frequently (primarily academic research). Very extensive family history of adhd and consistent collateral dating back to childhood as well. Very unusual cause, though.

 

[Stagg737]

Gotcha makes a ton of sense and I agree that ruling out other differentials is important. I think my cousin completed a GAD and PHQ-9 as part of his assessment but Ive given those before as a med student so that doesn't inspire me to believe. that is sufficient for ruling anxiety and depression out.

Any tips for a future PCP when it comes to managing patients asking about ADHD? I dont want to just refer to psych if I can do something thats actually helpful beforehand you know?

Couple of things that are moslty more common sense than truly medical but can be very telling:

1. If it's someone who hasn't been previously diagnosed as a child, why are they asking about it now? Is it causing marital problems? Are they about to lose their 5th job in 2 years? Did they decide to go back to get a PhD at 40 years old and they can't study like they used to? Did they see a video on TikTok? The answer to this is often very telling and sometimes will tell exactly what's going on. If all the patient does is hang out at home, doesn't work, doesn't have kids, isn't in school, etc then why are they asking for treatment? I recently got a consult for "ADHD?" in a recently retired 60-something year old who wanted "to function better" but couldn't tell me what that meant other than they weren't as sharp as they used to be.

2. What kind of dysfunction are their symptoms causing (if it's even legit ADHD)? "It's hard to concentrate" is neither pathognomic of ADHD nor a good reason to start stimulants yet it's the most common symptom people who think they have ADHD will report and want treatment for. Ask for specific examples. Do they have a hard time sitting down and reading a book for an hour or studying for extended periods? Guess what, that's normal. If they tell me they start folding a load of laundry, then get distracted by a commercial and that reminds them they need to do dishes which they start but then realize their cuticles need to be trimmed so they stop and go do that and then they get a text and forget what they're doing...that's worth a few more questions. How often do they lose their keys or phone? Have their memory issues ever caused problems? Ie, did they leave a stove on and leave the house or back through their garage door because they turned their car on before opening it and then were digging through stuff in their passenger seat looking for sunglasses and forgot the garage door was still closed? I have one patient whose new PCP didn't think she needed to be on stimulants she'd been on for 20+ years and had 2 car accidents in the following 2-3 months and ran mulitple stop signs because she got distracted while driving. Point is, not every bit of inconvenience or symptom warrants meds or even meet diagnostic criteria. If there's not real dysfunction, then why treat?

3. What are their treatment goals? Going along with dysfunction, this can be important. That 40 yo new PhD coming in saying "I need to be able to study for 3-4 straight hours like I did in undergrad" likely needs some counseling and a reality check. A mom coming in saying they've dealt with disorganization their whole life but now it's getting their K-5 kids in trouble due to tardiness or not having them ready is a reasonable concern. I take the goals of "I can't function in day to day life and have always been this way" more seriously than people needing to "optimize" themselves.

4. Are they willing to try non-stimulant options? The only time I start stimulants in a new ADHD patient is if they can prove they've been previously (appropriately) diagnosed and treated with a reasonable stimulant dose. If patients aren't willing to try bupropion or atomoxetine before stimulants, that should be a major red flag. I've consistently (almost 100%) found that patients with legit ADHD are willing to try any medication option that may be helpful and are fine with trying non-stimulants to avoid the hassles with prescribing and shortages, cost, and side effects of stimulants. They're typically also forthcoming about positives of non-stimulant meds after trying them even if they don't feel the med is a magic pill that completely fixes.

If you're a PCP and a patient is trying to establish with you just to get stimulants for "ADHD", that's a red flag. I would refer them to psychiatry. If it's a patient you've had for a while and the ADHD is obvious and you're comfortable prescribing stimulants, that's fine. Once you get some decent experience and knowledge, there will be patients who you can tell after sitting with them for 5 minutes that they probably have it (which should be confirmed on several follow-ups without meds).

 

[Stagg737]

Thank you for providing the additional information. Quite interesting that all of this additional collateral was unearthed. I literally have no idea where a single one of my old report cards has ended up lol. In my experience, as a pediatric psychologist, I typically find reports of "severe behavioral concerns such as "extreme difficulty listening to/following directions in class, completing assignments but forgetting to turn them in, rushing through assignments, and multiple comments about the need to think before acting" result in solid grades. Additionally, reflecting on DSM-5-TR criteria ("Section D: There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning") , suggest that if an individual can adapt through these and achieve the grades they did, without context of other problematic behaviors (social issues, impulsivity leading to significant issues, etc.) this is not representative of clinically significant impairment, and therefore not matching diagnostic criteria.

You did not specify which Barkley measures (there is actually quite a few), but I am very confused why you would administer both an adult and childhood measure...as the adult measures already inquires about childhood experiences...

So I'll push back on the bolded a bit as the DSM is terrible from a formulation perspective and using categorical models for diagnoses to fit patients into nice little boxes misses a lot of "clinically significant" issues. I'll add that I'm a fairly high-functioning psychiatrist with mild to moderate ADHD that I've had to develop a lot of coping skills to function with. I'm pretty good at hiding it (with a lot of conscious effort) from people who don't know me well. However, people who do know me well and know what ADHD is would laugh at the idea of me not having it. The amount of effort needed for me to consciously maintain social etiquette and functioning is at times completely exhausting and sometimes does cause psychological distress. Saying there is not active "clinically significant impairment" ignores non-medication related coping skills or efforts taken to maintain basic functioning.

Now, I do think it's a fair question to ask if someone like what I'm describing needs to be on stimulants or medications at all. If they can do well enough with coping techniques, therapy, and are satisfied with their functional level then I can see why someone would question if they have ADHD and deferring medications would certainly be reasonable. However, part of understanding level of dysfunction (with any diagnosis) is understanding what coping skills and techniques someone has to employ to mitigate symptoms. If someone is literally setting 100+ alarms per day to keep them on track or their spouse has to be their personal assistant and follow them around to keep them on task (both irl examples from some of my patients in residency), then that needs to be taken into account.

 

[futureapppsy2]

So I'll push back on the bolded a bit as the DSM is terrible from a formulation perspective and using categorical models for diagnoses to fit patients into nice little boxes misses a lot of "clinically significant" issues. I'll add that I'm a fairly high-functioning psychiatrist with mild to moderate ADHD that I've had to develop a lot of coping skills to function with. I'm pretty good at hiding it (with a lot of conscious effort) from people who don't know me well. However, people who do know me well and know what ADHD is would laugh at the idea of me not having it. The amount of effort needed for me to consciously maintain social etiquette and functioning is at times completely exhausting and sometimes does cause psychological distress. Saying there is not active "clinically significant impairment" ignores non-medication related coping skills or efforts taken to maintain basic functioning.

Now, I do think it's a fair question to ask if someone like what I'm describing needs to be on stimulants or medications at all. If they can do well enough with coping techniques, therapy, and are satisfied with their functional level then I can see why someone would question if they have ADHD and deferring medications would certainly be reasonable. However, part of understanding level of dysfunction (with any diagnosis) is understanding what coping skills and techniques someone has to employ to mitigate symptoms. If someone is literally setting 100+ alarms per day to keep them on track or their spouse has to be their personal assistant and follow them around to keep them on task (both irl examples from some of my patients in residency), then that needs to be taken into account.

Also, how much distress is it causing the patient? The person I mentioned above was so distressed by their ADHD symptoms that they sought therapy repeatedly over the course of several decades, and eventually concluded that their brain “was just fundamentally broken in some unique way” before getting assessed for ADHD.

 

[Stagg737]

Also, how much distress is it causing the patient? The person I mentioned above was so distressed by their ADHD symptoms that they sought therapy repeatedly over the course of several decades, and eventually concluded that their brain “was just fundamentally broken in some unique way” before getting assessed for ADHD.

To add onto this point, how much of that distress is due to ADHD versus an underlying primary anxiety disorder or adjustment disorder? Anxiety disorders are by far the most common diagnoses I make in patients who are referred to me for ADHD evals.

 

[futureapppsy2]

To add onto this point, how much of that distress is due to ADHD versus an underlying primary anxiety disorder or adjustment disorder? Anxiety disorders are by far the most common diagnoses I make in patients who are referred to me for ADHD evals.

Yes! Or concentration issues related to depression.

 

[Chromium Surfer]

Couple of things that are moslty more common sense than truly medical but can be very telling:

1. If it's someone who hasn't been previously diagnosed as a child, why are they asking about it now? Is it causing marital problems? Are they about to lose their 5th job in 2 years? Did they decide to go back to get a PhD at 40 years old and they can't study like they used to? Did they see a video on TikTok? The answer to this is often very telling and sometimes will tell exactly what's going on. If all the patient does is hang out at home, doesn't work, doesn't have kids, isn't in school, etc then why are they asking for treatment? I recently got a consult for "ADHD?" in a recently retired 60-something year old who wanted "to function better" but couldn't tell me what that meant other than they weren't as sharp as they used to be.

2. What kind of dysfunction are their symptoms causing (if it's even legit ADHD)? "It's hard to concentrate" is neither pathognomic of ADHD nor a good reason to start stimulants yet it's the most common symptom people who think they have ADHD will report and want treatment for. Ask for specific examples. Do they have a hard time sitting down and reading a book for an hour or studying for extended periods? Guess what, that's normal. If they tell me they start folding a load of laundry, then get distracted by a commercial and that reminds them they need to do dishes which they start but then realize their cuticles need to be trimmed so they stop and go do that and then they get a text and forget what they're doing...that's worth a few more questions. How often do they lose their keys or phone? Have their memory issues ever caused problems? Ie, did they leave a stove on and leave the house or back through their garage door because they turned their car on before opening it and then were digging through stuff in their passenger seat looking for sunglasses and forgot the garage door was still closed? I have one patient whose new PCP didn't think she needed to be on stimulants she'd been on for 20+ years and had 2 car accidents in the following 2-3 months and ran mulitple stop signs because she got distracted while driving. Point is, not every bit of inconvenience or symptom warrants meds or even meet diagnostic criteria. If there's not real dysfunction, then why treat?

3. What are their treatment goals? Going along with dysfunction, this can be important. That 40 yo new PhD coming in saying "I need to be able to study for 3-4 straight hours like I did in undergrad" likely needs some counseling and a reality check. A mom coming in saying they've dealt with disorganization their whole life but now it's getting their K-5 kids in trouble due to tardiness or not having them ready is a reasonable concern. I take the goals of "I can't function in day to day life and have always been this way" more seriously than people needing to "optimize" themselves.

4. Are they willing to try non-stimulant options? The only time I start stimulants in a new ADHD patient is if they can prove they've been previously (appropriately) diagnosed and treated with a reasonable stimulant dose. If patients aren't willing to try bupropion or atomoxetine before stimulants, that should be a major red flag. I've consistently (almost 100%) found that patients with legit ADHD are willing to try any medication option that may be helpful and are fine with trying non-stimulants to avoid the hassles with prescribing and shortages, cost, and side effects of stimulants. They're typically also forthcoming about positives of non-stimulant meds after trying them even if they don't feel the med is a magic pill that completely fixes.

If you're a PCP and a patient is trying to establish with you just to get stimulants for "ADHD", that's a red flag. I would refer them to psychiatry. If it's a patient you've had for a while and the ADHD is obvious and you're comfortable prescribing stimulants, that's fine. Once you get some decent experience and knowledge, there will be patients who you can tell after sitting with them for 5 minutes that they probably have it (which should be confirmed on several follow-ups without meds).

Oh my goodness thank you so much for taking the time to share this thoughtful reply! A lot of gems in here for sure. The representative anecdotes you shared and reflections on patient behaviors was super helpful for contextualizing as well. Definitely saving this in a folder somewhere haha. Thanks again! 🙂

 

[Chromium Surfer]

Not a healthcare practitioner of any description, personal anecdote only. I've been diagnosed with ADHD since early childhood, was also labeled as 'gifted' age 7 and attended one of the first gifted children programs in South Australia. 'Masking' in terms of academic performance (up to a point)? Yes. 'Masking' in terms of pretty much anything else symptom wise? A definite no. As I'm sure you already know ADHD affects performance across multiple spheres of life; being considered 'highly intelligent' might have allowed me to 'mask' to a degree in one area, but not across all of them.

Sorry I missed this comment but thanks for sharing your anecdote!🙂 They were labeled as "gifted" in high school. From our convos what he told me was that he had done fairly well in school and had been in honors classes but always somewhat unperformed on standardized exams at least relative to his school performance. But then in high school he scored in the 97th+ percentile on the practice ACT/SAT reading sections and was placed into gifted program which mostly just amounted to special counseling since he was already taking honors/ap classes.

His partner thought he was just being a careless dingus for doing stuff like leaving keys in the door when coming into their apartment(sometimes overnight) and/or taking keys out but not locking the door behind him. Also other little things like forgetting to do chores around the house after being asked to to or leaving cupboards open etc. Also when talking to him he has almost like a nonlinear approach to convos insofar as he might bring up things that seem totally out of place in conversation until he explains the tangential connection. He tends to bounce around from topic to topic generally. A lot of these "quirks" tbh seem to be somewhat aligned with ADHD at least now that I have done more research into it what it is, and this was one of the reasons I commented on this thread. But I am not a psychiatrist and lots of people have made good points on this thread about overdiagnosis etc.

 

[Chromium Surfer]

I actually do know a high-achieving physician who was diagnosed with ADHD in their 50s. Despite being high achieving, their profile was textbook ADHD-PI in many ways (goes off on tangents, has to be frequently redirected in conversation, late to almost everything, took an entire sabbatical primarily to mass delete the 1000s and 1000s of unread emails from their inbox, has entire days where they sit in front of the computer and don’t do anything because they keep being distracted by anything and everything, etc) with a long history of seeking assessment/treatment for it because they were chronically distressed by their inability to consistently complete stuff with no one ever making a diagnosis other than “just need a new work style” and recommending behavioral stuff that the patient could never remember to do or plan enough to implement . In this case, I honestly do think them being legitimately genius-level intelligent played into it, as did being in a job where productivity is assessed less frequently (primarily academic research). Very extensive family history of adhd and consistent collateral dating back to childhood as well. Very unusual cause, though.

Oh wow, again take my comments with a heavy dose of salt because of bias due to the familial connection and my lack of expertise in general but this comment made me laugh because of the similarities/parallels. Something we test him about is how he has literally over 100,000+ unread emails on his phone and he's always like well I respond to the ones that are important! But bro is it so hard to delete the rest of the emails lmao! I just replied to someone else but have definitely experienced him going off on tangents when we talk sometimes and he does have some epic stories of zoning out and/or going down rabbit holes on the computer. He was never like outwardly hyperactive as a kid though so maybe thats part of why no one ever thought to look into ADHD.

 

[aim-agm]

Another consideration in high-functioning individuals is that they can feel attention is a problem because it is an area of relative weakness that is a limiting factor for function, even though executive function is in isolation normal. Those can be somewhat difficult conversations.

Also, one soft sign to look for for impaired attention (although not specific to ADHD) is an overinclusive thought process.

 

[Ceke2002]

Sorry I missed this comment but thanks for sharing your anecdote!🙂 They were labeled as "gifted" in high school. From our convos what he told me was that he had done fairly well in school and had been in honors classes but always somewhat unperformed on standardized exams at least relative to his school performance. But then in high school he scored in the 97th+ percentile on the practice ACT/SAT reading sections and was placed into gifted program which mostly just amounted to special counseling since he was already taking honors/ap classes.

His partner thought he was just being a careless dingus for doing stuff like leaving keys in the door when coming into their apartment(sometimes overnight) and/or taking keys out but not locking the door behind him. Also other little things like forgetting to do chores around the house after being asked to to or leaving cupboards open etc. Also when talking to him he has almost like a nonlinear approach to convos insofar as he might bring up things that seem totally out of place in conversation until he explains the tangential connection. He tends to bounce around from topic to topic generally. A lot of these "quirks" tbh seem to be somewhat aligned with ADHD at least now that I have done more research into it what it is, and this was one of the reasons I commented on this thread. But I am not a psychiatrist and lots of people have made good points on this thread about overdiagnosis etc.

I had to laugh at the non linear conversation description. That is so me during a conversation as well. It's like you start off with a simple story to tell, but then the story needs context, and all of this backstory, to go with it, and then random tangential thoughts connected to the initial story come up that just have to be followed, and they need their own context and backstory, and then back to the original story, before the next tangential thought point that just has to be followed along the winding path like you're just constantly going on these really important conversational side quests that have to be completed before you finally meander back to the actual point.

I do manage my ADHD symptoms without medication (I was on dexamphetamine for a short while as an adult, I did not like the side effects of taking a daily stimulant), and a lot of what you've described with this guy does sound like the sort of things I would do on a bad day when I can't use non medication type stuff to limit my symptoms. Like others more knowledgeable have said though ADHD is overdiagnosed, and there are other things that can account for ADHD like symptoms. Obviously not being a healthcare professional I can't comment on whether this person's diagnosis is correct or not.

 

[romanticscience]

as many as 1 in 3 young people divert stimulants.

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.

@oliversacks4thewin This recent article may be interesting to you:

Prescription Stimulant Use, Misuse, and Use Disorder Among US Adults Aged 18 to 64 Years

This cross-sectional survey study examines the prevalence of prescription stimulant use, misuse, and use disorder among US adults aged 18 to 64 years.

jamanetwork.com

 

[oliversacks4thewin]

So I'll push back on the bolded a bit as the DSM is terrible from a formulation perspective and using categorical models for diagnoses to fit patients into nice little boxes misses a lot of "clinically significant" issues. I'll add that I'm a fairly high-functioning psychiatrist with mild to moderate ADHD that I've had to develop a lot of coping skills to function with. I'm pretty good at hiding it (with a lot of conscious effort) from people who don't know me well. However, people who do know me well and know what ADHD is would laugh at the idea of me not having it. The amount of effort needed for me to consciously maintain social etiquette and functioning is at times completely exhausting and sometimes does cause psychological distress. Saying there is not active "clinically significant impairment" ignores non-medication related coping skills or efforts taken to maintain basic functioning.

Now, I do think it's a fair question to ask if someone like what I'm describing needs to be on stimulants or medications at all. If they can do well enough with coping techniques, therapy, and are satisfied with their functional level then I can see why someone would question if they have ADHD and deferring medications would certainly be reasonable. However, part of understanding level of dysfunction (with any diagnosis) is understanding what coping skills and techniques someone has to employ to mitigate symptoms. If someone is literally setting 100+ alarms per day to keep them on track or their spouse has to be their personal assistant and follow them around to keep them on task (both irl examples from some of my patients in residency), then that needs to be taken into account.

The evolution of this discussion has become really fascinating and I enjoy the exchange of personal experiences, anecdotes, and collective thoughts. I want to directly address the story you so graciously shared. You shared how it diminished the quality of various facets in your own personal experience across the domains listed, which would be considered in line with DSM criteria. A skilled evaluator (psychologist, psychiatrist, etc.) is consistently evaluating all of this in the context of the story the patient and associated collaterals are providing. I feel like we just made the same argument of the significant nuance and difficulty in illuminating a neurodevelopmental condition (one of the strongest genetic correlate in psychiatry with roughly a 75% rate!) on the experiences of an adult reflecting on all of these factors. I agree, it requires a really critical eye towards spotting these areas where dysfunction present and manifest.

I recognize the DSM remains consistently controversial for a long period of time, due to disputes cited within your experiences, and other understandable concerns. Of note, the one large consistent piece of it is always highlighting the need for apparent dysfunction to collect symptoms to inform best practices of treatment and avoidance of over-diagnosing (which I believe is the concern brought up in this discussion thread). While an older article, here is a link to the ongoing debate and discussion in the literature, that I hope suggests a rationale for the benefits and possible pitfalls of consideration for reviewing symptoms from a distress/impairment framework:

https://journals.sagepub.com/doi/epdf/10.1177/070674371305801106

For a more casual read, this article from the Psychiatric Times, which directly speaks to patient populations on the harms of jumping to quickly to a diagnostic label for what could be considered idiosyncratic but relatively normative behaviors, environmental or internalized responses and reactions:

The Significance of Clinical Significance

As McHugh and Slavney propose in Perspectives of Psychiatry, disjunctive categories of symptoms such as this are part of the complexity of psychological evaluation and care of patients makes our field soo interesting compared to say, neurology. Which really highlights the importance of intersection of clinical judgement of neurobiological, psychological, and story, and less reliance on critical T or Z scores on these measures. This is a strong contention by Barkley, and part of the reason for his development of the measures we have discussed, which he often suggests be utilized in conjunction with skilled clinical judgement. Just curious too... has there been more clarity on why both child and adult versions (and which specific ones?) were administered?

 

[Chromium Surfer]

The evolution of this discussion has become really fascinating and I enjoy the exchange of personal experiences, anecdotes, and collective thoughts. I want to directly address the story you so graciously shared. You shared how it diminished the quality of various facets in your own personal experience across the domains listed, which would be considered in line with DSM criteria. A skilled evaluator (psychologist, psychiatrist, etc.) is consistently evaluating all of this in the context of the story the patient and associated collaterals are providing. I feel like we just made the same argument of the significant nuance and difficulty in illuminating a neurodevelopmental condition (one of the strongest genetic correlate in psychiatry with roughly a 75% rate!) on the experiences of an adult reflecting on all of these factors. I agree, it requires a really critical eye towards spotting these areas where dysfunction present and manifest.

I recognize the DSM remains consistently controversial for a long period of time, due to disputes cited within your experiences, and other understandable concerns. Of note, the one large consistent piece of it is always highlighting the need for apparent dysfunction to collect symptoms to inform best practices of treatment and avoidance of over-diagnosing (which I believe is the concern brought up in this discussion thread). While an older article, here is a link to the ongoing debate and discussion in the literature, that I hope suggests a rationale for the benefits and possible pitfalls of consideration for reviewing symptoms from a distress/impairment framework:

https://journals.sagepub.com/doi/epdf/10.1177/070674371305801106

For a more casual read, this article from the Psychiatric Times, which directly speaks to patient populations on the harms of jumping to quickly to a diagnostic label for what could be considered idiosyncratic but relatively normative behaviors, environmental or internalized responses and reactions:

The Significance of Clinical Significance

As McHugh and Slavney propose in Perspectives of Psychiatry, disjunctive categories of symptoms such as this are part of the complexity of psychological evaluation and care of patients makes our field soo interesting compared to say, neurology. Which really highlights the importance of intersection of clinical judgement of neurobiological, psychological, and story, and less reliance on critical T or Z scores on these measures. This is a strong contention by Barkley, and part of the reason for his development of the measures we have discussed, which he often suggests be utilized in conjunction with skilled clinical judgement. Just curious too... has there been more clarity on why both child and adult versions (and which specific ones?) were administered?

Thank you for sharing this thoughtful reflection, and I am looking forward to reading the articles you shared!

I assume the question at the end of this comment was for me? If so unfortunately I dont have much insight regarding the choices that the psychologist made in terms of the assessments they conducted. But while reading the report he received what I saw was that the specific Barkley scales he completed were the BAARS-IV Current Symptoms Form(which was also completed by his partner) and the BAARS-IV Childhood Symptoms Form, which was just completed by him. At least from my cursory search it seems that the first form only covers symptoms from the last 6 months but since I am a layman I'm sure I could be missing some important context!

 

[R. Matey]

the BAARS-IV Current Symptoms Form(which was also completed by his partner) and the BAARS-IV Childhood Symptoms Form, which was just completed by him

The BAARS-IV has a current symptom and childhood symptom form to the assessment. I presume that's what you mean. There is also an other report for childhood symptoms, typically completed by someone who can speak to their symptoms under age 12. Not a great substitution for a collateral interview, but it's a little odd the psychologist gave the BAARS other report form without including the collateral childhood symptoms form.

 

[Chromium Surfer]

The BAARS-IV has a current symptom and childhood symptom form to the assessment. I presume that's what you mean. There is also an other report for childhood symptoms, typically completed by someone who can speak to their symptoms under age 12. Not a great substitution for a collateral interview, but it's a little odd the psychologist gave the BAARS other report form without including the collateral childhood symptoms form.

gotcha yeah I didnt see the actual forms that he completed but that makes sense to me thanks for the insight! Yeah this thread has made me think about the schema that different professions use when deciding what assessments to administer. When you do ADHD assessments do you normally give the full WAIS or just parts of it when trying to get a baseline of intellectual functioning and to rule out learning disorders?

 

[R. Matey]

gotcha yeah I didnt see the actual forms that he completed but that makes sense to me thanks for the insight! Yeah this thread has made me think about the schema that different professions use when deciding what assessments to administer. When you do ADHD assessments do you normally give the full WAIS or just parts of it when trying to get a baseline of intellectual functioning and to rule out learning disorders?

Since ADHD can occur at all levels of intellectual functioning, it's not necessary to give a WAIS at all to establish a credible diagnosis. In some settings, such as academic settings where there is a question of academic accommodations and a need to rule out a learning disability, psychologists may use these tests to differentiate ADHD from LDs (though, in the case of ADHD, many academic accommodations are not evidenced based). However, it's not necessary to rule out a learning disorder if there is no suspicion of a learning disorder.

 

[WisNeuro]

Since ADHD can occur at all levels of intellectual functioning, it's not necessary to give a WAIS at all to establish a credible diagnosis. In some settings, such as academic settings where there is a question of academic accommodations and a need to rule out a learning disability, psychologists may use these tests to differentiate ADHD from LDs (though, in the case of ADHD, many academic accommodations are not evidenced based). However, it's not necessary to rule out a learning disorder if there is no suspicion of a learning disorder.

Yeah, more important with differential diagnoses, and usually higher yield in pediatric settings. There's LDs, and there's just plain old below average intellectual functioning that leads to poor academic performance at times. But, if anything, I see the WAIS leading to more misdiagnoses than anything, as incompetent evaluators will over interpret mild differences as diagnostic. "All their scaled scores were generally 9-10, but DS was an 8, definitely ADHD!"

 

[Merovinge]

Since ADHD can occur at all levels of intellectual functioning, it's not necessary to give a WAIS at all to establish a credible diagnosis. In some settings, such as academic settings where there is a question of academic accommodations and a need to rule out a learning disability, psychologists may use these tests to differentiate ADHD from LDs (though, in the case of ADHD, many academic accommodations are not evidenced based). However, it's not necessary to rule out a learning disorder if there is no suspicion of a learning disorder.

I can see that being true if only answering the question ADHD or not. But as a CAP the IQ testing was one of the, if not the most, helpful tests given as part of any psychologic battery to my school-aged patients. It really helps to understand what the expectation should be, particularly when compared to current academic achievement testing and seeing if anything stands out.