interesting articles on adult ADHD

[Jules A]

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It's called "transference" when it's the patient's feelings about the therapist.

Gee thanks, for that tidbit.
I was trying to compliment you on your self-awareness. My point was there are also psychiatrists with countertransference who over diagnose/prescribe, in my opinion. There can be a flavor of that in these threads sometimes.

 

[randomdoc1]

I met a psychiatrist today who has his own adult ADHD clinic. I was really curious as to if he is a strong advocate of this or is doing it for the heck of it. Apparently he gathers no collateral, especially from people who can give a better developmental history. He says his rationale is that we don't get collateral on depressed people, so why get collateral for adults reporting they have ADHD, well, because we're not the best historians of ourselves as kids. He knows nothing about the MTA data or major figures/authorities on the topic of ADHD. He even says he doesn't care if a PHQ-9 is screaming severe MDD. He still feels ADHD is underdiagnosed. Although I agree that you won't always find something if you don't look for it, I find some of his rationale is rather odd and the lack of knowledge about major texts on ADHD concerning. He also does that weird MRI stuff for his clients...ah well, c'est la vie. *shudders*

I wonder if that guy himself is on stimulants...seriously.

 

[Ceke2002]

Agreed. And so we are left to consider what is the likely percentage of adults who continue having symptoms to a degree so significant it requires a stimulant?

I'd hazard a lay person's guess that the percentage of adults who actually need a stimulant to treat ADHD is a lot, lot lower than the percentage who either think they do, or are already on one.

I think part of the problem comes from the types of books and other information that is marketed/presented to the average lay person with ADHD, wherein the emphasis seems to be more typically on medication as the 'gold standard' treatment, and even other non medication therapies are discussed as being performed 'in conjunction with medication'. I know for me personally that sort of information ended up placing stimulant medication up on a sort of pedestal, like that was going to be some sort of miracle solution (and consequently I wasted a lot of time that otherwise could have been used exploring other treatment modalities).

Just personally I'd like to see a lot more education and information out there on non medication based treatments for ADHD, that don't sound like they're coming from a bunch of quacks, or the anti psychiatry brigade (which I think is unfortunately another factor in the 'medication is the only thing that will work' idea that many patients become fixated on).

 

[erg923]

I met a psychiatrist today who has his own adult ADHD clinic.

I would have stopped inquiring about his thoughts once this was disclosed.

 

[Ceke2002]

It doesn't sound like a substance abuse problem although keep in mind that those who do are very practiced at hiding it. Whether or not the person has potential for abuse, if you don't think they have ADHD, then try to provide the help that they need. Be upfront and direct about it. Medications have risk and your job is to minimize risk by only prescribing medications when appropriate. I find it hard to say no too and got sucked into something messy with a school district a few weeks back because of that.

I can understand Doctors attitudes towards patients either looking for, or claiming a diagnosis of ADHD; particularly when it comes to stimulant medication. I think I'd be the same, especially with my background and knowing the tricks of the trade, so to speak, that a good pill scammer will use to manipulate a physician into giving them what they want.

The response/attitude towards ADHD is definitely the reason I insisted my (now former) Psychiatrist note on my diagnosis/therapy summary letter that whilst I might have a diagnosis of ADD/ADHD I do not take medication for it, nor do I wish to take medication for it. Last thing I'd want, if I do decide to see another Psych where I'm living now, is to go to an appointment and have them see 'ADHD' and just automatically be thinking, "Oh great, here we go."

 

[Trismegistus4]

I feel your pain Trismegistus4. An appropriate ADHD evaluation requires a lot of grunt work that is poorly reimbursed if at all. I did this when I first started my practice and had the time, but in most cases, I find people have already made up their minds and just leave angry they're not getting 70mg of Vyvanse with 10mg Adderall IR five times a day for break through (jk). Some reasonable protocols you can apply which could weed some folks out who truly are not in it for the right reason include random UDS (with confirmation as you can sometimes get false positives) and getting an ROI to speak with someone who can give a good reliable developmental history. If they refuse, then I say I'm not able to give them an appropriate evaluation (my understanding is there is data that shows how we see things now can strongly distort our perceptions of ourselves in the past). You can also try to apply the Barkley and I believe there is a way you can bill for that as an MD but again, I would inform them I really need a person I can speak with who can give a reliable history. I also would not tell them specifically I am getting a Barkley and just say I will be using some scales (because some patients will try to get their family to give scripted answers), I just say I need to gather collateral and slip in the Barkley questions while also asking about other psychiatric symptoms. But it ultimately boils down to getting a good developmental history. Also, another place where the truth really comes out as to if they really do have ADHD is if they truly have impairment in 2+ settings. Most of the people who came to me just complained about work and apparently everything else was great...that doesn't really match up well. I'm just looking forward to setting up my own shop, you've probably seen my other threads. I'm getting a nice sexy website up and found a sleek and smokin' hot building to rent from full of other medical specialties. I'm in good enough financial standing that I can afford the high end look of the place and I'll be subspecializing in depression, anxiety, some PTSD, applying TMS. I'm just telling folks that sorry, ADHD is not my specialty, but here is a list of people who may be able to help and have a nice day.

Bumping this thread because I have a question for @randomdoc1 and any others who have decided to adopt a policy of simply not "doing" ADHD: are your referrals screened? That is, when a new patient calls to make an initial appointment, are then queried as to the reason for the appointment, and, if their reply mentions ADHD, told then and there that you are not the doctor for them, and not put on your schedule in the first place? If not, how far out are you booked? If the patient just made the appointment last week, and you wind up having to tell them to their face at the appointment that "ADHD is not my specialty, but here is a list of people who may be able to help and have a nice day," I can see that, but if not, how do you deal with a steady stream of people who have been waiting 3 months to see you for this and it's finally their big day to score "their" Adderall and start their brand new life?

Also, how does everyone in this thread handle established patients, whom you have been seeing for a long time for some diagnosis other than ADHD, who suddenly start bringing up ADHD concerns? This has come up in several cases for me recently: someone I've been seeing for depression, bipolar, PTSD, or something else, for 6 months or more, stable and well-controlled by now, and who never complained of inattention or poor concentration before, and/or never told me, even during my thorough initial intake, about a childhood history of ADHD, will come in one day for what I think is going to be routine follow-up, and instead sit down and start right in with "OMG, Doc! I never told you this before, but when I was a kid, I was diagnosed with ADHD and put on Ritalin, did well, got off it in high school because I thought I didn't need it anymore, but my mom's been pointing out how I don't even sit down to eat and am always pacing and fidgeting, and I can't concentrate at work or get anything done around the house! I need to be back on ADHD meds!" or "I was never diagnosed with ADHD as a kid, but since I saw you last time, I can't concentrate or pay attention to anything, and I started researching ADHD online and everything I've read fits me to a T, and my mother/sister/aunt/boss/professor/girlfriend/pastor/personal trainer/AA sponsor/tennis doubles partner/mailman/infant son/dog all tell me they're sure I have it and need to be on Adderall!" And I'm totally at a loss, because this person has gone from zero to sixty, from person who never mentioned any concerns for ADHD, inattention, or poor concentration before, to grade-A aggressive stimulant-demander in between routine checkups. I've seen 2-3 long term patients of mine in the past couple of weeks who have done this. Do you guys get this very often, and if so, how do you approach it?

Gee thanks, for that tidbit.
I was trying to compliment you on your self-awareness. My point was there are also psychiatrists with countertransference who over diagnose/prescribe, in my opinion. There can be a flavor of that in these threads sometimes.

Sorry, I see what you meant now. I don't know why I misinterpreted your post. I must have read only part of it because of my ADHD.

 

[randomdoc1]

Hey there! Yes, as feasible, I screen and deter patients before they even get through the door. It's just easier that way. As for the established patients, often there is an established rapport and I tell them up front my clinical impression and how I feel a stimulant may or may not be beneficial and I cite the data. If they insist, I offer them my handy dandy list and say it's not my primary specialty and if this is something they are really interested in, we can discuss transitioning their care as management of stimulants can be very tricky and then I discuss the slippery slope of tolerance and addiction thus the reason I don't manage it.

 

[MacDonaldTriad]

You could put on your web site: "If you are looking for Benzos or stimulants, don't bother making an appointment." You can still use them, but you will not get the people who have already decided what they need.

 

[splik]

You could put on your web site: "If you are looking for Benzos or stimulants, don't bother making an appointment." You can still use them, but you will not get the people who have already decided what they need.

I don;t think that will work. you will just come up in the searches when they google benzo stimulant psychiatrist 🙁

 

[Trismegistus4]

Hey there! Yes, as feasible, I screen and deter patients before they even get through the door. It's just easier that way. As for the established patients, often there is an established rapport and I tell them up front my clinical impression and how I feel a stimulant may or may not be beneficial and I cite the data. If they insist, I offer them my handy dandy list and say it's not my primary specialty and if this is something they are really interested in, we can discuss transitioning their care as management of stimulants can be very tricky and then I discuss the slippery slope of tolerance and addiction thus the reason I don't manage it.

Thanks, I just wanted to get a sense of whether screening referrals is something that can be done or that many docs do. My current job is my first permanent job, so I have nothing to compare it to, and as I've said, looking at the reason for referrals is just not part of our process. It's basically just secretaries running down a first-in-first-out queue of referrals, calling them, and offering them an appointment. And this is a big organization so I don't have the power to change that. Nice to know it can be done when you have a say in running the place. This is definitely something to ask about when one is considering taking an employed position.

You could put on your web site: "If you are looking for Benzos or stimulants, don't bother making an appointment." You can still use them, but you will not get the people who have already decided what they need.

If I had my own private practice, I would do that. My organization actually has a little blurb on our website saying that we do treat ADHD.

 

[MacDonaldTriad]

I don;t think that will work. you will just come up in the searches when they google benzo stimulant psychiatrist 🙁

How about Gabaminergic or dopaminergic psychotropic agents. Of course anything that would fool Google would not be understood by patients.

 

[MacDonaldTriad]

If I had my own private practice, I would do that. My organization actually has a little blurb on our website saying that we do treat ADHD.

That's a problem. You either put up with it, threaten to quit, or compromise and insist they add in "Childhood onset ADHD"
Before anyone reminds me that ADHD doesn't have an age criteria, it is in the disorders of infancy and childhood or adolescence chapter of DSM.

 

[nathanerey]

Will check out the articles, but my initial thoughts are you'd probably need a more thorough review of why there wasn't a childhood diagnosis of ADHD. We know it's not uncommon for the condition to go undiagnosed in childhood, particularly if the person is intellectually high-functioning, otherwise able to compensate, in an impoverished school district, overshadowed by "worse" kiddos/siblings, etc. Wouldn't surprise me at all that there are cases where it first comes to a head in the tumultuousness of adolescence, although I'd still be surprised if there weren't symptoms of it in childhood (based on our current understanding of the developmental etiology).

And I could've mis-read based on my initial cursory summary, but I didn't get the feel that either of the first two articles was purporting an actual adult-onset ADHD. Per the first article, "There was no evidence for adult-onset ADHD independent of a complex psychiatric history." Which to me says, "the cluster of symptoms known as ADHD sometimes shows up in adulthood, but it's being caused by things that aren't really ADHD."

Hi,

As far as I know you can be diagnose with ADHD in your childhood, its either you did not notice you have it or you pretend that you don't have it.

 

[deleted103644]

Hi everyone. I was reading this month's edition of the American Journal of Psychiatry and found a couple of interesting articles and also found an older article in another journal about this hot topic.

The two articles below already state what we've been discussing (e.g. need for a thorough evaluation, etc.).

Sibley, M. H., Rohde, L. A., Swanson, J. M., Hechtman, L. T., Molina, B. S., Mitchell, J. T., ... & Stehli, A. (2017). Late-onset ADHD reconsidered with comprehensive repeated assessments between ages 10 and 25. American Journal of Psychiatry, appi-ajp.

Paris, J., Bhat, V., & Thombs, B. (2015). Is adult attention-deficit hyperactivity disorder being overdiagnosed?. The Canadian Journal of Psychiatry, 60(7), 324-328.

But what do you all think of this third article which argues there is validity literally in adult onset ADHD? It says even when assessing for comorbidity (e.g. AODA, mood disorders, anxiety disorders, etc.) there seems to actually be ADHD that starts as an adult. I find it interesting and wonder if this is more of a cultural phenomena (e.g. partially a byproduct of heavy marketing as well as the fact that we are now having to work harder and are in more direct competition with other countries). It would interesting to see if other countries are reporting similar prevalences of adult onset ADHD or this is specific to the US. As you may have guessed, I am skeptical until more literature comes out that supports this.

"Growing Up: Evolving Concepts of Adult Attention Deficit Hyperactivity Disorder." American Journal of Psychiatry, 175(2), pp. 95–96

TL; DR.

 

[JSizzles]

I really hate this, "adult-onset ADHD" nonsense. There is no such thing. Dysfunction or impairment from symptoms may not manifest until early adulthood, if someone has the intellectual ability to compensate. However, independent of dysfunction, there should exist the presence of symptoms during childhood. This is pretty clear in the DSM criteria, which literally states that symptoms should have been present prior to the age of 12. Notice that the criteria states that symptoms must be present before this age -- not dysfunction or impairment.

As mentioned above, there can certainly be something else that presents in adulthood with symptoms very similar to ADHD, but this would be diagnosed as the, "something else", and not ADHD.

I generally agree with your statement regarding intellectual ability helping compensate for and mask adhd symptoms. However, I would be wary of sticking to the dsm word for word. I find that too many of my colleagues get hung up on diagnostics. Half of my adult patients on stimulants (and doing very well on them) my “true diagnostician” colleagues wountdnt have prescribed anything. Or in my practice some only write adults strattera (even patients with no reason to suspect abuse), which doesn’t even give them a fighting chance.

 

[Liquid8]

My take on "adult onset" ADHD is that there probably was some level of dysfunction in childhood, which you will only find if you look hard enough. Conversely if there isn't something that strikes me as being out of the ordinary, I tend to be more sceptical about the diagnosis.

Recently saw someone with their parents. There was an established family history of ADHD, mainly hyperactivity subtype that had responded well to treatment, but the patient didn't think they had anything wrong with them themselves. They reported some daydreaming, lapses in concentration - not doing great in their studies but didn't think they had any obvious dysfunction. They didn't recall any issues in school, and told me they were really organised and well behaved. Compared to the rest of the family, they certainly were.

Yet later on they said they would lose their bank card and have to order a new one. How often? 10 times over the last few years. Has this happened with other things? As a kid they misplaced their train card and get a new one at the station each time - once found 30-40 of them in the school bag at the end of the year.

Dug around a bit more and found other things to justify a diagnosis, but the patient was ambivalent about having treatment which always makes things easy - have a think about it, talk about it with your family a bit more, and come back in a few months once you've decided.

 

[hamstergang]

Half of my adult patients on stimulants (and doing very well on them) my “true diagnostician” colleagues wountdnt have prescribed anything.

This sentence confuses me. If you have many patients on controlled substances where you think other psychiatrists wouldn't have made the diagnosis of ADHD or given any prescription, wouldn't that suggest you're the one doing something wrong? How does this support you not being so strict with the diagnosis?

 

[VA Hopeful Dr]

This sentence confuses me. If you have many patients on controlled substances where you think other psychiatrists wouldn't have made the diagnosis of ADHD or given any prescription, wouldn't that suggest you're the one doing something wrong? How does this support you not being so strict with the diagnosis?

That and if you give a normal person a stimulant, they will often do well on it. So not really a good point to support the practice.

 

[WisNeuro]

That and if you give a normal person a stimulant, they will often do well on it. So not really a good point to support the practice.

Come on man, everyone knows that someone reporting that they focus better on a stimulant is the one 100% specific and sensitive diagnostic indicator of ADHD.

 

[Attending1985]

That and if you give a normal person a stimulant, they will often do well on it. So not really a good point to support the practice.

THIS! I work in an area where several psychiatrists and nps throw stimulants at everything. The patient of course reports improvement and everything is great! What a disaster. I have been reading Nassir Ghaemi’s take on the neurotoxicity of stimulants. That and the new evidence they increase risk of Parkinson’s makes me very weary to prescribe them at all.

 

[Attending1985]

My take on "adult onset" ADHD is that there probably was some level of dysfunction in childhood, which you will only find if you look hard enough. Conversely if there isn't something that strikes me as being out of the ordinary, I tend to be more sceptical about the diagnosis.

Recently saw someone with their parents. There was an established family history of ADHD, mainly hyperactivity subtype that had responded well to treatment, but the patient didn't think they had anything wrong with them themselves. They reported some daydreaming, lapses in concentration - not doing great in their studies but didn't think they had any obvious dysfunction. They didn't recall any issues in school, and told me they were really organised and well behaved. Compared to the rest of the family, they certainly were.

Yet later on they said they would lose their bank card and have to order a new one. How often? 10 times over the last few years. Has this happened with other things? As a kid they misplaced their train card and get a new one at the station each time - once found 30-40 of them in the school bag at the end of the year.

Dug around a bit more and found other things to justify a diagnosis, but the patient was ambivalent about having treatment which always makes things easy - have a think about it, talk about it with your family a bit more, and come back in a few months once you've decided.

If the patient is not describing any dysfunction how can you make a diagnosis based on the fact they lose their bank card every few months. I don’t understand this type of digging. Sounds like creating issues where there are none. Slapping a label on someone can also be harmful even without stimulant treatment.

 

[Liquid8]

If the patient is not describing any dysfunction how can you make a diagnosis based on the fact they lose their bank card every few months. I don’t understand this type of digging. Sounds like creating issues where there are none. Slapping a label on someone can also be harmful even without stimulant treatment.

It’s called making a judgement call.

A psychotic patient with persecutory delusions, responding to internal stimuli and lacking the required insight still has psychosis and still has a problem even if they think the don’t – and to not treat that would be completely unethical. Conversely a patient who tells me that they need to be put on a disability pension due to “hearing voices” but on further questioning describe hearing a voice coming out of the lower left quadrant of their right ear probably has a personality disorder rather than a primary psychotic condition.

If you accept that, then why would the above principles not also apply to making an ADHD assessment? Someone who loses their bank card, and has to cancel it to order a new one multiple times clearly has an issue that goes beyond a normal level of absentmindedness, and this was just one single example as I obviously wasn't going to include the full case history.

If you choose not to dig deeper, then to some extent that demonstrates a lack of curiosity. If you don’t clarify a patients symptoms you’re going to miss stuff and in some cases have a very difficult time working out exactly what is going on. Am I to assume that you accept everything a patient says at face value? That would be a worry if it were the case. How you ask the question is also important too. If one relies on simple yes/no questions you’ll probably end up over-diagnosing conditions and getting fooled by drug seekers. Any patient who quote a checklist but struggles to “tell me more” doesn’t get a diagnosis.

 

[clausewitz2]

It’s called making a judgement call.

A psychotic patient with persecutory delusions, responding to internal stimuli and lacking the required insight still has psychosis and still has a problem even if they think the don’t – and to not treat that would be completely unethical. Conversely a patient who tells me that they need to be put on a disability pension due to “hearing voices” but on further questioning describe hearing a voice coming out of the lower left quadrant of their right ear probably has a personality disorder rather than a primary psychotic condition.

If you accept that, then why would the above principles not also apply to making an ADHD assessment? Someone who loses their bank card, and has to cancel it to order a new one multiple times clearly has an issue that goes beyond a normal level of absentmindedness, and this was just one single example as I obviously wasn't going to include the full case history.

If you choose not to dig deeper, then to some extent that demonstrates a lack of curiosity. If you don’t clarify a patients symptoms you’re going to miss stuff and in some cases have a very difficult time working out exactly what is going on. Am I to assume that you accept everything a patient says at face value? That would be a worry if it were the case. How you ask the question is also important too. If one relies on simple yes/no questions you’ll probably end up over-diagnosing conditions and getting fooled by drug seekers. Any patient who quote a checklist but struggles to “tell me more” doesn’t get a diagnosis.

So much this. The death of descriptive psychopathology in American psychiatric training may be partly responsible, since fewer and fewer people even know what to ask about or what sort of things to expect to hear from patients with particular presentations. Why get into it if you won't know what to do with the information and it is not relevant to the operationalized criteria?

Incidentally this is why I feel so deskilling working with people with intellectual disability and assessing for comorbidity. Like, are you struggling to provide me with more than "I'm depressed" because you are misidentifying another experience, or because you are really bad at words?

 

[randomdoc1]

THIS! I work in an area where several psychiatrists and nps throw stimulants at everything. The patient of course reports improvement and everything is great! What a disaster. I have been reading Nassir Ghaemi’s take on the neurotoxicity of stimulants. That and the new evidence they increase risk of Parkinson’s makes me very weary to prescribe them at all.

I’ve heard of this too! I’ll have to do some reading on this. But the stims versus no stims question. It boils down to risks versus benefits just like when prescribing anything. The goal of psychiatry is to restore function, but if there isn’t impairment/dysfunction/distress I have a hard time justifying adding yet another medication. There is also mention in the American journal of psychiatry that subjective report of benefit with the stimulant does not seem to correlate with objective improvement in performance. Don’t recall where I read that, but it was in one of the 2018 issues.

 

[WisNeuro]

I’ve heard of this too! I’ll have to do some reading on this. But the stims versus no stims question. It boils down to risks versus benefits just like when prescribing anything. The goal of psychiatry is to restore function, but if there isn’t impairment/dysfunction/distress I have a hard time justifying adding yet another medication. There is also mention in the American journal of psychiatry that subjective report of benefit with the stimulant does not seem to correlate with objective improvement in performance. Don’t recall where I read that, but it was in one of the 2018 issues.

https://www.sciencedirect.com/science/article/pii/S089085671730566X
https://onlinelibrary.wiley.com/doi/full/10.1111/ajad.12718

 

[Old&InTheWay]

Is this discussion focused specifically on people who were not diagnosed/treated for ADHD as children?

 

[MacDonaldTriad]

Is this discussion focused specifically on people who were not diagnosed/treated for ADHD as children?

I think the answer is both yes and no. Yes, we are talking about "Adult" ADHD as a rationalization to give out stimulants. No, having been treated for ADHD as a child probably doesn't give you any immunity to what ever neurotoxicity stimulants have.

 

[WisNeuro]

I think the answer is both yes and no. Yes, we are talking about "Adult" ADHD as a rationalization to give out stimulants. No, having been treated for ADHD as a child probably doesn't give you any immunity to what ever neurotoxicity stimulants have.

I think some people are using terms interchangeably. Which can be confusing, given many possible definitions that people are using. There are people with ADHD who were diagnosed as children and have symptoms of significance that have persisted into adulthood. There are individuals who had ADHD as a kid and were never diagnosed, for whatever reason, and still have symptoms as an adult. And, there are people with no discernible clinical history of ADHD as a child, but are complaining of symptoms starting in adulthood.

 

[Old&InTheWay]

I think some people are using terms interchangeably. Which can be confusing, given many possible definitions that people are using. There are people with ADHD who were diagnosed as children and have symptoms of significance that have persisted into adulthood. There are individuals who had ADHD as a kid and were never diagnosed, for whatever reason, and still have symptoms as an adult. And, there are people with no discernible clinical history of ADHD as a child, but are complaining of symptoms starting in adulthood.

I guess I am curious because I see a bunch of people on this thread who seem to be saying that they won’t treat adults for ADHD with stimulant medication. But in my limited experience, there is absolutely a subset of people who have had ADHD their entire lives and continue to require stimulant medication to help with focus/executive functioning deficits. I just don’t see a compelling reason to not treat these folks if they are accepting of the risks.

 

[VA Hopeful Dr]

I guess I am curious because I see a bunch of people on this thread who seem to be saying that they won’t treat adults for ADHD with stimulant medication. But in my limited experience, there is absolutely a subset of people who have had ADHD their entire lives and continue to require stimulant medication to help with focus/executive functioning deficits. I just don’t see a compelling reason to not treat these folks if they are accepting of the risks.

I don't think many people object to that part. If you're been on stimulants since age 6, I have no issue prescribing.

When you show up at age 40, can't focus, and haven't mentioned this to anyone until 3 weeks ago that's a different story.

 

[WisNeuro]

I guess I am curious because I see a bunch of people on this thread who seem to be saying that they won’t treat adults for ADHD with stimulant medication. But in my limited experience, there is absolutely a subset of people who have had ADHD their entire lives and continue to require stimulant medication to help with focus/executive functioning deficits. I just don’t see a compelling reason to not treat these folks if they are accepting of the risks.

As @VA Hopeful Dr is getting at in a way, it's the people that are reporting complaints that are beginning in their 30s or beyond. Because, in most circumstances, the cause is something besides ADHD (e.g., normal cognitive aging, anxiety, depression, sleep apnea, and so on and on). I, for one, would rather my patients with untreated sleep apnea be evaluated for such, rather than be given a stimulant off the bat for reporting what sounds like symptoms of ADHD to the lazy interviewer.

 

[Jules A]

I guess I am curious because I see a bunch of people on this thread who seem to be saying that they won’t treat adults for ADHD with stimulant medication. But in my limited experience, there is absolutely a subset of people who have had ADHD their entire lives and continue to require stimulant medication to help with focus/executive functioning deficits. I just don’t see a compelling reason to not treat these folks if they are accepting of the risks.

Consider defining "a bunch". While I agree there are those with ADHD since childhood who still require treatment with a stimulant as an adult what percentages of those with ADHD and the general population would that be? I believe them to be a small subset and the numbers of adults on stimulants or seeking them recently appears disproportionate to the actual expected probability.

 

[randomdoc1]

Consider defining "a bunch". While I agree there are those with ADHD since childhood who still require treatment with a stimulant as an adult what percentages of those with ADHD and the general population would that be? I believe them to be a small subset and the numbers of adults on stimulants or seeking them recently appears disproportionate to the actual expected probability.

85% of the new patient inquiries were for stims when I first started PP. Very interesting stats indeed.

 

[Old&InTheWay]

Consider defining "a bunch". While I agree there are those with ADHD since childhood who still require treatment with a stimulant as an adult what percentages of those with ADHD and the general population would that be? I believe them to be a small subset and the numbers of adults on stimulants or seeking them recently appears disproportionate to the actual expected probability.

Sorry, I didn't count; suppose I should have said "several" or "a few." I can see how having many people requesting meds they don't need can make things more complicated. The response of just throwing up one's hands and saying "no stimulants for anyone then!" doesn't feel quite right to me though (but I suppose every provider needs to figure out what works for them and their personality in the long run). I think what WisNeuro said above makes a lot of sense to me; that you need to have a high degree of skepticism and be duly diligent in ruling out any other possible causes of the symptoms (including malingering).

 

[cara susanna]

There's this trend at the VA where I work that psychiatrists want psych testing for ADHD before they will even consider prescribing stimulants to an adult without prior testing. We non-neuro psychologists typically see the patient for what we call a screen (CPT, patient and observer rating scale, clinical interview). Sometimes there are cases where, IMO, it's pretty clear cut: there's a clear childhood history and DSM-5 criteria is currently met, plus the testing is supportive of the diagnosis. However, even then sometimes the psychiatrist isn't satisfied and the patient gets referred by the psychiatrist for further neuropsych testing. My understanding from the neuropsych people here and that I've met during my own training is that neuropsych testing isn't helpful for diagnosing ADHD. Yet neuropsych accepts these referrals for further testing, which makes me wonder if I'm clearly missing something or misinformed on this subject. Anyone care to share their thoughts on this matter?

 

[AcronymAllergy]

There's this trend at the VA where I work that psychiatrists want psych testing for ADHD before they will even consider prescribing stimulants to an adult without prior testing. We non-neuro psychologists typically see the patient for what we call a screen (CPT, patient and observer rating scale, clinical interview). Sometimes there are cases where, IMO, it's pretty clear cut: there's a clear childhood history and DSM-5 criteria is currently met, plus the testing is supportive of the diagnosis. However, even then sometimes the psychiatrist isn't satisfied and the patient gets referred by the psychiatrist for further neuropsych testing. My understanding from the neuropsych people here and that I've met during my own training is that neuropsych testing isn't helpful for diagnosing ADHD. Yet neuropsych accepts these referrals for further testing, which makes me wonder if I'm clearly missing something or misinformed on this subject. Anyone care to share their thoughts on this matter?

Neuropsych testing isn't needed for ADHD, and isn't particularly helpful/accurate in diagnosing it. Sure, some studies find that folks with h/o ADHD perform worse than controls on some tests, but this varies by study, and the PPP/NPP of the findings aren't particularly confidence-inspiring. Basically, some people with ADHD do worse on some neuropsych tests, and some don't.

It can be helpful if there are multiple potential etiologies that you're wanting to try and clarify. But for straight ADHD, it's generally a waste of time; when I get those referrals, it's usually because I have more time available in my appointments to conduct a thorough interview and administer some rating scales, and/or the referring provider doesn't want to/isn't able to do it themselves. However, there are still some neuropsychologists (and "neuropsychologists") out there who hold the belief that the testing is indeed helpful for diagnosing ADHD, which might explain why you're seeing some people accept the referrals (that, or there's administrative pressure to do so).

You could try and make the argument that neuropsych can also help quantify a person's cognitive functioning, identify strengths/weaknesses, etc., and is useful for ADHD in that regard, but that's tenuous and none of it is medically necessary.

And of course none of the above should be confused for psychoeducational testing, which is helpful with ADHD, but which isn't covered by any health insurance I've ever seen.

 

[AcronymAllergy]

Case in point: pt referred to neuropsych (by a psychologist) for straightforward ADHD eval. Has also already been seen by a MH NP who's now prescribing Adderall. And has an eval by a different outside provider (LMHC) apparently indicating ADHD. Remind me why this consult is making it to me?

 

[WisNeuro]

Case in point: pt referred to neuropsych (by a psychologist) for straightforward ADHD eval. Has also already been seen by a MH NP who's now prescribing Adderall. And has an eval by a different outside provider (LMHC) apparently indicating ADHD. Remind me why this consult is making it to me?

Because you're still in the VA 🙂

 

[erg923]

Case in point: pt referred to neuropsych (by a psychologist) for straightforward ADHD eval. Has also already been seen by a MH NP who's now prescribing Adderall. And has an eval by a different outside provider (LMHC) apparently indicating ADHD. Remind me why this consult is making it to me?

Unless that psychologist is in PCMHI, where consultation over 30 minutes is often prohibitive, it just strikes of not wanting to deal with it. Not that I really blame him/her, though.

Little in psychiatry/clinical psychology is more boring than vague attention problems and "insomnia." I long ago concluded the military must have a class on how to **** up sleep during bootcamp. Normal psychological resilience and reset of the circadian rhythm over time does not seem to apply/register with these folks.