evidence based assessment for ADHD (adults or children)

[nicsaminechce]

Hi All,

I wonder whether you could advice on evidence-based comprehensive ADHD assessment for kids or adults. What should be part of it? I mean , even when looking at the literature, there is no validity and worth in administering CPT-3. what do you guys do? in addition, questionnaires can be faked, and CPT as well.

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[WisNeuro]

This is a different assessment whether or not it is in an adult or a child. And, neuropsych testing is not indicated unless you are trying to rule out an LD/ID, or an underlying neuropathological issue. Or if you want to get at areas of strength and weakness for possible intervention. Anyone who diagnoses ADHD based off the CPT/TOVA/whatever, is an idiot.

 

[nicsaminechce]

This is a different assessment whether or not it is in an adult or a child. And, neuropsych testing is not indicated unless you are trying to rule out an LD/ID, or an underlying neuropathological issue. Or if you want to get at areas of strength and weakness for possible intervention. Anyone who diagnoses ADHD based off the CPT/TOVA/whatever, is an idiot.

I know, so what would be the battery?
I mean there is so much controversy. I am getting frustrated.

 

[nicsaminechce]

OK let me be specific:
so for adults
WAIS (look at working memory and Processing speed)
WJ-4 (is it LD why they struggle at college)
BRIEF-A (childhood, self and other report, parent reported)
SCID-5 to check other conditions
CPT? (hate this test)
BAARS (self and other report) - easily being faked.
unstructured interviews- childhood history
interview with parents
school report cards
ANYTHING ELSE?

What about kids?

 

[WisNeuro]

The battery depends on the referral question. If the question in adults is simply "does this person have ADHD?" there is no testing battery.

 

[nicsaminechce]

The battery depends on the referral question. If the question in adults is simply "does this person have ADHD?" there is no testing battery.

yes, there is where i get frustrated.

 

[WisNeuro]

Frustrated with what? And why?

 

[nicsaminechce]

Frustrated with what? And why?

well, you have a college student who wants comprehensive eval to find out whether he "is ADHD or not". so what do you do?

 

[erg923]

OK let me be specific:
so for adults
WAIS (look at working memory and Processing speed)
WJ-4 (is it LD why they struggle at college)
BRIEF-A (childhood, self and other report, parent reported)
SCID-5 to check other conditions
CPT? (hate this test)
BAARS (self and other report) - easily being faked.
unstructured interviews- childhood history
interview with parents
school report cards
ANYTHING ELSE?

What about kids?

Most of this is a waste of time (and money for whoever is footing the bill) unless you have a strong suspicion the person is intellectually disabled or has a learning disability. So what if their working memory is high or low? So what if processing speed is high or low? These domains are too nonspecific to be helpful in making the diagnosis or not.

History taking/gathering, rating scales (WURS, barkely, or Connors) and a good clinical interview. Maybe a CPT, more so for symptom validity check.

Why is this frustrating? Tailoring your assessments to the specific question and circumstances is responsible practice and resource utilization.

 

[nicsaminechce]

Most of this is a waste of time (and money for whoever is footing the bill) unless you have a strong suspicion the person is intellectually disabled or has a learning disability. So what if their working memory is high or low? So what if processing speed is high or low? These domains are too nonspecific to be helpful in making the diagnosis or not.

History taking/gathering, rating scales (WURS, barkely, or Connors) and a good clinical interview. Maybe a CPT.

Why is this frustrating? Tailoring your assessments to the specific question and circumstances is responsible practice and resource utilization.

Thanks guys...

 

[WisNeuro]

Really depends on local clinic policies. Is this for accommodations? If so, the university may have some required elements. Best bet, consult with a supervisor who has gone through the drill in that specific context.

 

[nicsaminechce]

Really depends on local clinic policies. Is this for accommodations? If so, the university may have some required elements. Best bet, consult with a supervisor who has gone through the drill in that specific context.

Yes, It seems places may have different "batteries" or comprehensive testings, and tests they prefer, I just feel that - well it is hard to decide, even if you do comprehensive testing. but thanks.

 

[erg923]

Yes, It seems places may have different "batteries" or comprehensive testings, and tests they prefer, I just feel that - well it is hard to decide, even if you do comprehensive testing. but thanks.

Why is this hard to decide? Tests never diagnose anything. You do. Hopefully based on good clinical assessment...which doesn't necessarily mean giving a bunch of tests.

Comorbidity is also the rule, not the exception in psychiatry, and this is especially true with fuzzy and heterogeneous entities like AD/HD. In other words, the "not better accounted for by" clause in the DSM-5 its not something that necessarily requires test results to conclude. In fact, informed clinical judgment, so long as one has firm grasp of the phenomenology and presentation of various psychiatric disorders, is generally all that is needed.

Assessing for possible AD/HD in adults is not easy, I'm just not sure giving a bunch of tests makes it any easier, or ultimately, any more accurate.

 

[Therapist4Chnge]

well, you have a college student who wants comprehensive eval to find out whether he "is ADHD or not". so what do you do?

Cash pay or I don't take the case. If they want to go through their insurance on the backend, that's up to them. Too many insurances reject billing that even lists ADHD anywhere on it. These days I decline any ADHD eval bc they are of limited use in many cases and I'd rather see other types of referrals.

The most effective approach I've found is to only take referrals that include a clear medical condition (e.g. TBI), and have the reported symptoms listed, but not list ADHD bc legit evals with a clear medical necessity incorrectly get flagged by the insurance company bc ADHD was mentioned once in the referral.

ADHD eval is very much a cottage industry. As long as the eval helps the pt and the clinicians are clear about the limitations of eval (in regard to dx), then I don't have a problem with the niche.

 

[AcronymAllergy]

Agree with the above. As WisNeuro mentioned, the ultimate purpose of the evaluation is an important factor. If the client is thinking of pursuing accommodations should the eval come back "positive," then it's helpful to review the battery requirements of the accommodating agency (as it seems you've already done). This can also help you structure the report.

Beyond this, there isn't much agreement on a typical testing battery, other than: A) a full neuropsych isn't necessary for "uncomplicated" ADHD evals; B) use of symptom report measures (in addition to a thorough interview) is typically recommended; C) request childhood records whenever possible; and D) request collateral interview/report whenever possible.

Part of the hodgepodge of findings may reflect that fact that we haven't done a good job of properly delineating ADHD and its subtypes (and differentiating them from other conditions that may present similarly), and that our tests or the testing environments aren't particularly good at picking up on/eliciting the cardinal problems of ADHD.

 

[nathanerey]

ADHD in adults doesn't mean that you have it when you are adult. Maybe you have it when you are a child but you didn't notice it or there is no proper assessment and diagnosis.

 

[WisNeuro]

 

[erg923]

ADHD in adults doesn't mean that you have it when you are adult.

What?

 

[nathanerey]

evidence-based treatment is not just for kids but it is also for adults. It is also called as Cogmed working memory training

 

[erg923]

It is also called as Cogmed working memory training

What?

 

[WisNeuro]

evidence-based treatment is not just for kids but it is also for adults. It is also called as Cogmed working memory training

"Cogmed" and "evidence based" don't yet belong in the same sentence. Unless we're talking about the lack or inadequacy of the latter term.

 

[bcliff]

IMO: (1.) intake interview potentially supplemented with some normed measures (e.g., checklists, neuropsychological tasks), (2.) brief, time-limited cognitive-behavioral therapy for ADHD (i.e., the only EST for adult ADHD presentations per Div. 12), (3.) reevaluation to support (a.) continued utility of psychotherapy, (b.) differential diagnosis, (c.) appropriateness of outside referral.

 

[AcronymAllergy]

I'm interested, but not particularly optimistic, to see what happens with Cogmed.

And yes, +1 for CBT for ADHD. I once made a vague reference, in passing, to starting up a group for such, and the psychiatrists here nearly tackled me to ask when they could start referring patients.

 

[cara susanna]

Any resources people would be willing to share on CBT for ADHD? I'm not familiar with it and there's definitely a need for it here in our clinic!

 

[bcliff]

Any resources people would be willing to share on CBT for ADHD? I'm not familiar with it and there's definitely a need for it here in our clinic!

Cognitive Behavioral Therapy for adult ADHD | Society of Clinical Psychology -- Entry on Div. 12 website with key references

Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction -- Treatment manual (only $23)

Per the manual, the treatment is designed to be implemented in a group format, but there are recommended accommodations and adjustments that can be made for one-on-one implementation.

 

[DynamicDidactic]

From my understanding, the evidence base is pretty solid for CBT in conjunction with medication treatment for adults. Does better than meds alone.

Its a fun treatment when I looked over the manual. Some very novel and ingenious ideas to improve sustained attention skills.

 

[smalltownpsych]

I'm interested, but not particularly optimistic, to see what happens with Cogmed.

And yes, +1 for CBT for ADHD. I once made a vague reference, in passing, to starting up a group for such, and the psychiatrists here nearly tackled me to ask when they could start referring patients.

Is it just me or is the idea running a therapy group made up of people with ADHD sound like a good idea for an SNL skit? Or maybe I just need to move on to my new job already. 😀