First time adult ADHD assessment

[ObsequiousAplomb]

Which side effects are most common and bothersome for your patients?

for Effexor, it's jitteriness, increased anxiety, insomnia, headaches, dry mouth, dry eyes, and inter-dose withdrawal symptoms.

Patients switching to imipramine from Effexor, in my limited experience, mention mostly dry mouth, dry eyes, but they specify that these are less dry than they were with Effexor. Again, in my limited experience, the Effexor was usually augmented with Abilify, which caused 20 lb+ weight gain and only minimal improvement in primary mood symptoms. Obviously, I'm only seeing the patients that were so upset by this that they switched psychiatrists.

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[Candidate2017]

Again, in my limited experience, the Effexor was usually augmented with Abilify, which caused 20 lb+ weight gain and only minimal improvement in primary mood symptoms. Obviously, I'm only seeing the patients that were so upset by this that they switched psychiatrists.

Nothing says personality disorder (and refusal to meaningfully participate in therapy) like antidepressant + antipsychotic augmentation, then switching to a new doctor instead of working with one's doctor regarding side effects.

 

[ObsequiousAplomb]

Nothing says personality disorder (and refusal to meaningfully participate in therapy) like antidepressant + antipsychotic augmentation, then switching to a new doctor instead of working with one's doctor regarding side effects.

I am much less selective than I ought to be.

 

[Merovinge]

I admit that most of my patients at least convincingly pretend to be wary of stimulants when I'm discussing risks, benefits, and alternatives. I think that's why most at least play the game of asking for something other than a schedule II at the first visit. I also admit y'all've convinced me and I'll be ordering screening UDSs for everyone over the next few months and see how it goes. Hopefully I won't be too surprised.

I saw that 30% of Americans may be iron deficient recently. Think we should be screening that more seriously?

It's great that you are trying something new and seeing how it goes.

I actually don't do iron studies unless there is anemia, but absolutely would if there was pica or RLS concerns. I get a lot of lab testing compared to the average psychiatrist due to a sicker patient population who has high eating disorder or SUD comorbidity. I see a variable testing pattern with Fe in non-anemic patients, with a lot of PCPs ordering this in menstruating females. Due to where in the country I live I get a lot of Vit D tests and catch levels <20 a handle of times/year where repletion seems to make a real difference.

 

[Stagg737]

Nothing says personality disorder (and refusal to meaningfully participate in therapy) like antidepressant + antipsychotic augmentation, then switching to a new doctor instead of working with one's doctor regarding side effects.

Idk. I think a patient telling you that you're the best doctor they've ever had and that you're the only one who has actually cared about them as a person then finding out from an inpatient/consult team 3 months later that the patient was sobbing, telling them how horrible of a doctor you were and that "they wouldn't even give me the meds I needed!" says it a little better, lol.

 

[Ceke2002]

I admit that most of my patients at least convincingly pretend to be wary of stimulants when I'm discussing risks, benefits, and alternatives. I think that's why most at least play the game of asking for something other than a schedule II at the first visit. I also admit y'all've convinced me and I'll be ordering screening UDSs for everyone over the next few months and see how it goes. Hopefully I won't be too surprised.

I saw that 30% of Americans may be iron deficient recently. Think we should be screening that more seriously?

Personal anecdotal experience only here, but as someone who used to doctor shop (not ADHD meds, we already had top quality stuff on the streets, why waste time bothering a Doctor) for pills the bolded section sets off red flags galore for me. That's exactly the sort of stuff I would've tried to pull.

 

[ObsequiousAplomb]

I am much less selective than I ought to be.

Also, to be clear, these patients have discussed side effects with the original doctor, who generally told them that the side effect they're having is impossible despite the specific side effect being abundantly common (weight gain with Abilify augmentation in TRD, etc)

 

[DoubtfulDoc]

I use the DSM-5 cross-cutting symptom measure. I evaluate the domains the patient positively endorses using the SCID-5-CV. The ADHD module asks if several symptoms were present before age twelve.

To assess for severity, I use the ADHD-RS with my own embedded validity testing (Becke, 2021). I used the CAT-A, but it became too cumbersome to score.

In line with the literature (Ahmad, 2019; Sibley, 2018), complaints of ADHD in adults usually come along with significant co-morbidity. So, usually, after going through the SCID, I'm telling someone that I can't diagnose ADHD because something else better explains it. That something else is usually severe MDD, bipolar, PTSD--dissociative disorder, or substance use. I will usually make a co-morbid diagnosis if anxiety is mild or depression is remitted or part of persistent depressive disorder.

I've been getting many young women with really, really bad PTSD, avoiding their trauma and related emotions, coming to me FROM A THERAPIST for "suspected ADHD." Um, that's hypervigilance!

Yes, doing SCIDs on everyone does take time, but it is easier to tell someone it's likely not ADHD when you tell them their four other diagnoses in need of treatment.

My opinion is that the criteria for ADHD, which were formulated for children, become very non-specific when used in adults who have co-morbid "adult disorders." When I give my PTSD+BPD patients an ASRS, they score off the charts every time!


Ahmad, S. I., Owens, E. B. & Hinshaw, S. P. Little Evidence for Late-Onset ADHD in a Longitudinal Sample of Women. J. Consult. Clin. Psychol. 87, 112–117 (2019).
Becke, M. et al. Non-credible symptom report in the clinical evaluation of adult ADHD: development and initial validation of a new validity index embedded in the Conners’ adult ADHD rating scales. J. Neural Transmission 128, 1045–1063 (2021).
Sibley, M. H. et al. Late-Onset ADHD Reconsidered With Comprehensive Repeated Assessments Between Ages 10 and 25. Am. J. Psychiatry 175, 140–149 (2018).

Can you share the Becke 2021 scoring tool you use to score the ACI?

 

[romanticscience]

Sure, I PM'd you!

 

[psychma]

In adults, I do a clinical interview and try to get good examples of how the symptoms look in their lives. I ask about when their symptoms first started (what age/grade) and ask them to describe what those symptoms were. I also ask about teacher reports and sometimes I’ve lucked out and gotten old report cards. have them fill out a Brief-2A. I also use the CAT-A to look at childhood symptoms, but it’s not a standalone diagnostic tool. I screen for substance abuse, and comorbid anxiety or depression. Among other things.

 

[lol.psych]

In adults, I do a clinical interview and try to get good examples of how the symptoms look in their lives. I ask about when their symptoms first started (what age/grade) and ask them to describe what those symptoms were. I also ask about teacher reports and sometimes I’ve lucked out and gotten old report cards. have them fill out a Brief-2A. I also use the CAT-A to look at childhood symptoms, but it’s not a standalone diagnostic tool. I screen for substance abuse, and comorbid anxiety or depression. Among other things.

For me, getting examples of how ?ADHD shows up has been extremely helpful. As has asking how tf they got through elementary or high school as the little tornadoes that they describe.

I’ve had pts who had super attentive parents/caregivers (who hovered and prodded to do homework or study for exams) go from being A students in HS to having a 2.0 GPA in college, or taking many extra years to finish college, because they no longer had their hovering parent serving as a sort of auxiliary/accessory frontal lobe.

(Edited for clarity and after reflection) Also, my geographic area is relatively crunchy/hippy-dippy, so I have many (now adult) pts whose anti-psych parents went to great lengths to avoid interfacing with healthcare/psych when my pts were kids. So my experience may not translate.
I do also have the benefit of most of my pts seeing me for both therapy and pharm, so I get to know them and their childhoods way more than I would otherwise.

(Also edit: and fwiw, not all of them need or get stimulants, but some do. And when stimulants work, it can be extremely rewarding to see)

 

[FlowRate]

I’ve had pts who had super attentive parents/caregivers (who hovered and prodded to do homework or study for exams) go from being A students in HS to having a 2.0 GPA in college, or taking many extra years to finish college, because they no longer had their hovering parent serving as a sort of auxiliary/accessory frontal lobe.

I'm not saying that you're saying this, but that history alone would not cause me to assume someone has ADHD. That could be caused by so many other things, like the infantilization by parents leading to never developing independent organization, time management, and study strategies, or not having actual internal motivation to succeed in comparison to parents' expectations/consequences/etc.

While I'm certain there are several posters on this forum who will disagree, I find it somewhat hard to imagine that someone getting straight-A's in AP/IB classes and passing those exams with high marks has inattentive-type ADHD.

 

[lol.psych]

I'm not saying that you're saying this, but that history alone would not cause me to assume someone has ADHD. That could be caused by so many other things, like the infantilization by parents leading to never developing independent organization, time management, and study strategies, or not having actual internal motivation to succeed in comparison to parents' expectations/consequences/etc.

While I'm certain there are several posters on this forum who will disagree, I find it somewhat hard to imagine that someone getting straight-A's in AP/IB classes and passing those exams with high marks has inattentive-type ADHD.

Of course it’s not enough. That would be absurd. But I think a lot of folks get all side-eye about pts presenting for assessment for the first time in adulthood, so I felt compelled to offer some reasonable examples of how that might happen 🤷🏻

 

[Candidate2017]

For me, getting examples of how ?ADHD shows up has been extremely helpful. As has asking how tf they got through elementary or high school as the little tornadoes that they describe.

I’ve had pts who had super attentive parents/caregivers (who hovered and prodded to do homework or study for exams) go from being A students in HS to having a 2.0 GPA in college, or taking many extra years to finish college, because they no longer had their hovering parent serving as a sort of auxiliary/accessory frontal lobe.

Going from H.S. 4.0 to college 2.0 due to lack to parental nagging isn't ADHD. There are many reasons a H.S. 4.0 doesn't translate into a college 4.0: immaturity, lack of discipline, poor study habits from H.S. that don't translate to college, partying, drugs/alcohol, BF-GF breakups, difficult majors, step up in competition, going to a competitive non-Ivy college (i.e., A's aren't handed out left and right like Adderall), etc.

 

[psychma]

Going from H.S. 4.0 to college 2.0 due to lack to parental nagging isn't ADHD. There are many reasons a H.S. 4.0 doesn't translate into a college 4.0: immaturity, lack of discipline, poor study habits from H.S. that don't translate to college, partying, drugs/alcohol, BF-GF breakups, difficult majors, step up in competition, going to a competitive non-Ivy college (i.e., A's aren't handed out left and right like Adderall), etc.

I do agree with this for the most part. I worked with children for several years who had ADHD. They had great, supportive parents that sat and helped with homework, organization and emotional regulation. And I used the tools in my toolbox too. At the end of the day though, the kids with adhd with great parental support didn’t get that completed homework back to school to be graded. They lost their library books, didn’t bring home permission slips because they just shoved them into their overflowing, messy and disorganized desks, didn’t pay attention in class, moved their desks forward inch by inch until they touched the back of someone’s chair and got in trouble, were sometimes disruptive by blurting things out? and had difficulty making friends due to impulsive behaviors, like knocking over someone’s blocks after they had proudly built a tower and I think due to the fact that the child was often being reprimanded or redirected in front of them. They got reputations with their peers that were hard to get rid of even as things improved. That’s on the extreme end but what I’m pointing out is that with adhd you can sit with your child and do their homework with them if they remembered to bring it home, but unless you hand carried it to the teacher it might not get there. And you can’t control their inability to pay attention, focus, and regulate their emotions and impulses at school. I know there are inattentive types that can do better and that there exceptions especially in mild forms of adhd. But I’m bored, so I’m just sharing my experiences.

 

[Ceke2002]

I do agree with this for the most part. I worked with children for several years who had ADHD. They had great, supportive parents that sat and helped with homework, organization and emotional regulation. And I used the tools in my toolbox too. At the end of the day though, the kids with adhd with great parental support didn’t get that completed homework back to school to be graded. They lost their library books, didn’t bring home permission slips because they just shoved them into their overflowing, messy and disorganized desks, didn’t pay attention in class, moved their desks forward inch by inch until they touched the back of someone’s chair and got in trouble, were sometimes disruptive by blurting things out? and had difficulty making friends due to impulsive behaviors, like knocking over someone’s blocks after they had proudly built a tower and I think due to the fact that the child was often being reprimanded or redirected in front of them. They got reputations with their peers that were hard to get rid of even as things improved. That’s on the extreme end but what I’m pointing out is that with adhd you can sit with your child and do their homework with them if they remembered to bring it home, but unless you hand carried it to the teacher it might not get there. And you can’t control their inability to pay attention, focus, and regulate their emotions and impulses at school. I know there are inattentive types that can do better and that there exceptions especially in mild forms of adhd. But I’m bored, so I’m just sharing my experiences.

Your experiences are appreciated and highly relatable, to me at least. Having been first diagnosed at a very young age, in the mid 1970s, I think it's fair to say I was one of the kids with a more extreme presentation. All the parental engagement in the world would not have stopped me from forgetting and/or losing things (school texts, pencils, pens, homework assignments, etc); nor did it prevent me from interrupting the entire class by not being able to sit still during quiet work time; loudly blurring out questions and answers; actually just straight up wandering out of the classroom and sitting in a different class all together (we had open plan classrooms at this time) because something seemed way more interesting over there; randomly deciding to perform a ballet routine in the middle of a lesson, because why not; impulsively moving the desks and chairs into an entirely different configuration, whilst the teacher is writing something on the blackboard I'm supposed to be paying attention to, but hey I've just had this brilliant idea about rearranging the furniture, and so on. Yeah maybe having supportive and engaged parents might have helped to a degree, but it certainly wouldn't have removed symptoms entirely.

 

[clausewitz2]

I'm not saying that you're saying this, but that history alone would not cause me to assume someone has ADHD. That could be caused by so many other things, like the infantilization by parents leading to never developing independent organization, time management, and study strategies, or not having actual internal motivation to succeed in comparison to parents' expectations/consequences/etc.

While I'm certain there are several posters on this forum who will disagree, I find it somewhat hard to imagine that someone getting straight-A's in AP/IB classes and passing those exams with high marks has inattentive-type ADHD.

I can imagine someone with inattentive-type ADHD getting As in AP and IB classes but would also expect to see poor grades/much less demanding classes in areas they don't care about or do not find intrinsically interesting. The classic kid who flies through AP Physics and AP Calc and then fails gen pop English because he can't bring himself to do the reading or write "dumb" essays, all grown up.

 

[Stagg737]

I can imagine someone with inattentive-type ADHD getting As in AP and IB classes but would also expect to see poor grades/much less demanding classes in areas they don't care about or do not find intrinsically interesting. The classic kid who flies through AP Physics and AP Calc and then fails gen pop English because he can't bring himself to do the reading or write "dumb" essays, all grown up.

This was basically me. Got pretty much straight A’s through high school, including 4-5 AP classes without even studying, but remember my parents being furious about my C- in basic history. First time I’d ever fallen asleep in class and I did it regularly. I remember getting detention freshman year on my birthday because I forgot a Spanish project that I’d worked on all weekend. Also struggled starting sophomore year in college because I never learned to study and never had to. I learned to study pretty effectively, but still couldn’t do it for more than 15-20 minute spurts. Got dropped from multiple study groups because of it. Never got medicated until residency (Wellbutrin) and the difference was immense. Went from leaving work at 6-7pm regularly to being done around noon. I’ll also note, I actually enjoy taking tests (yes, I enjoyed taking psychiatry boards and the MCAT) so I’ve always thought the whole “Someone with ADHD would be failing” is BS. Like you point out, it’s more nuanced than this.

I’ve seen quite a few people like me, and plenty who have “ADHD” as an adult. I don’t think it’s particularly hard to differentiate them, but that may be because I’ve experienced it myself and know how to ask very specific questions to get at whether it’s actually ADHD.

IMO the most difficult patients are the ones with lower intelligence who may legit have inattentive ADHD. Hard to tell if it’s actually ADHD when they can barely describe anything (even basic feelings) beyond superficial buzz words.

Going from H.S. 4.0 to college 2.0 due to lack to parental nagging isn't ADHD. There are many reasons a H.S. 4.0 doesn't translate into a college 4.0: immaturity, lack of discipline, poor study habits from H.S. that don't translate to college, partying, drugs/alcohol, BF-GF breakups, difficult majors, step up in competition, going to a competitive non-Ivy college (i.e., A's aren't handed out left and right like Adderall), etc.

Not sure if you’re aware of the whole grade inflation issue at the Ivies, but A’s absolutely are handed out like candy. A couple of years ago a report showed that 79% of all grades at Harvard were in the A range, up from 60% in 2010. At one point so many kids (over 90%) were graduating “with honors” that the school capped it so only 60% could graduate with honors (which is still crazy imo).

IMO the only real impressive part about attending an Ivy today is getting in.

ETA link on inflation: Explore the Causes and Impacts of Harvard’s Grade Inflation - Crimson Education AU.

 

[Ceke2002]

This was basically me. Got pretty much straight A’s through high school, including 4-5 AP classes without even studying, but remember my parents being furious about my C- in basic history. First time I’d ever fallen asleep in class and I did it regularly. I remember getting detention freshman year on my birthday because I forgot a Spanish project that I’d worked on all weekend. Also struggled starting sophomore year in college because I never learned to study and never had to. I learned to study pretty effectively, but still couldn’t do it for more than 15-20 minute spurts. Got dropped from multiple study groups because of it. Never got medicated until residency (Wellbutrin) and the difference was immense. Went from leaving work at 6-7pm regularly to being done around noon. I’ll also note, I actually enjoy taking tests (yes, I enjoyed taking psychiatry boards and the MCAT) so I’ve always thought the whole “Someone with ADHD would be failing” is BS. Like you point out, it’s more nuanced than this.

I’ve seen quite a few people like me, and plenty who have “ADHD” as an adult. I don’t think it’s particularly hard to differentiate them, but that may be because I’ve experienced it myself and know how to ask very specific questions to get at whether it’s actually ADHD.

Sounds like you and I have had very similar experiences. Up to a certain point I could get away with half-ar5ing subjects that didn't interest me, and still manage to scrape together a passing grade. The less interest I had in a subject, and the more complex that subject got, the more outright fails I had on my report card. A's across the board if the subject interested me; a massive struggle to even muster a D grade if it didn't.