Neuropsych for ADHD can be helpful to gather some data about basic abilities, but it really isn't very good for differentiating a diagnosis of ADHD. It's not a good use of time or resources in most cases. I don't take ADHD referrals for a number of reasons, but a big one is that it usually doesn't add much to a case ONLY interested in ADHD.
The problem is that this doesn't get in the way of shady providers looking to make a buck off of patients paying out of pocket. The two predominant scenarios I've seen are (1) desperate parents willing to do and pay whatever ever they have to help their kid even if it isn't necessary or demonstrably helpful (thereby being taken advantage of by the unscrupulous) and (2) patients looking to buy a diagnosis for some reason (e.g., accommodations on high stakes testing.Another reason to avoid ADHD referrals, generally can't bill insurance for them.
Too much to gain for malingerers who want highly addictive stimulant medication.We have already done this, at least twice in the past 2 years. Maybe we can combine threads so we don't have to repeat??? I will repeat some general summaries here:
The most reliable and valid way to diagnose most psychiatric conditions is by using a structured clinical interview/examination (as opposed to one's own idiosyncratic clinical interviewer session...which is prone to lack of follow-up, distraction, laziness, poor question wording, lack of adherence to DSM criteria, and not attending to the "not otherwise accounted for by" clause of DSM), observation during session, and collateral information that is then supplemented by some normative/rating scale data. And yes, this might take more than 60 minutes. Sorry. This is not new, surprising, or controversial to anyone who is even the least bit up-to-date on the matter. Many psychologists, for whatever reason, seem not to understand this, even though it is well spelled out in the literature. The "test boundness" of some psychologists is, frankly, embarrassing.
Additional information is needed for some things and situations/cases though...of course.
Although it is possible for researchers to learn quite a bit about ADHD from small-to-modest mean differences in test performance, attention tests do not improve individual diagnostic accuracy because problems with attention (or any other cognitive function) are not part of the DSM criteria. And there is a reason for that.
It is common for clinical psychology supervisors not too care much about what is needed, efficient, discriminatory, or actually translatable to a treatment plan, etc when training grad students. They aren't billing for it and you need to learn how to give instruments anyway. So, why not? I dont really agree with this philosophy of training, but its the predominate one out there.
There are a quite a view myths out there in assessment-land. At least to the point that they are not as discriminatory as many psychologists seem to believe, or that they do not really translate into substantially changing the treatment that will ultimately be rendered to the patient. Testing that is needed for accommodations is just that. For educational accommodations/recommendations. Its not for diagnosis or for medical/psychiatric treatment planing.
If you are already confident (in either direction) about whether ADHD is the correct diagnosis, there are no cognitive test results in the world that should undermine your confidence. The evidence simply does not exist for this. And the DSM criteria reflect this evidence base, as there is no measurable deficits in attention or other cognitive domain as part of the diagnostic criteria.
Not the most up to date, but it's a start. We can all cherry-pick studies of course...but we need to keep in mind the idea of preponderance of the scientific/empirically evidence and literature here. There is a difference between clinically significant vs statically significance differences. Research vs Clinical application, etc.. And there is also what is "needed/necessary and pragmatically useful" vs what is "curiosity" on the part of the provider or patient.
Your tax dollars pay for psycho-educational evaluations. FPL 94-142 requires school systems to identify and provide adequate services for children with disabilities. This does not have to come "out- of-pocket" (all my children are in Catholic school and are still required to be covered by this, by the way), nor should it be the be responsibility of a health insurance company. Someone is already paying for it (i.e., you).
Lastly, doing a large (or even a small) battery of tests/testing that includes symptom validity testing for every self-reported ADHD case is cost and resourceful prohibitive and is not a viable solution to the clinical examination of this disorder.
People can fake the developmental history of ADHD. People can fake schizophrenia and depression too, right? But we don't "test" them ad naseum to prove it, do we? And what do we do about that? We articulate our clinical evidence and clinical opinion for such. It happens every day.
There is no "lower bar" for educational testing. This is already covered by a payor source. That paryor source is you/tax payer. Thus, these questions should first be assessed and triaged by said payor source (the school system) before being given to a provider billing health insurance policies.
Doyle, A.E., Biederman, J., Seidman, L.J.,Weber,W., & Faraone, S.V. (2000). Diagnostic efficiency of neuropsychological test scores for discriminating boys with and without ADHD. Journal of Consulting and Clinical Psychology, 68, 477–488.
Elwood, R. W. (1993). Clinical discriminations and neuropsychological tests: An appeal to Bayes’ theorem. The Clinical Neuropsychologist, 7(2), 224−233.
Frazier, T. W., Demaree, H. A., & Youngstrom, E. (2004). Meta-analysis of intellectual and neuropsychological test performance in Attention Deficit Hyperactivity Disorder. Neuropsychology, 18, 543−555.
Goldstein, S., & Kennemer, K. (2009). Neuropsychological aspects of attention-deficit hyperactivity disorder. In C. R. Reynolds & E. Fletcher-Janzen (Eds.), Handbook of Clinical Child Neuropsychology (3rd ed.; pp. 617−633). New York, NY: Springer.
Grodzinsky, G. M., & Barkley, R. A. (1999). Predictive power of frontal lobe tests in the diagnosis of attention deficit hyperactivity disorder. The Clinical Neuropsychologist, 13(1), 12−21.
Schwean, V. L., & Saklofske, D. H. (2005). Assessment of Attention Deficit Hyperactivity Disorder with the WISC-IV. In A. Prifitera, D. H. Saklofske, & L. G. Weiss (eds.), WISC-IV clinical use and interpretation: Scientist-practitioner perspectives (pp. 235–280). San Diego, CA: Elsevier Academic Press.
Woods, S. P., Lovejoy, D. W. & Ball, J. D. (2002). Neuropsychological characteristics of adults with ADHD: A comprehensive review of initial studies. The Clinical Neuropsychologist, 16(1), 12−34.
The problem is that this doesn't get in the way of shady providers looking to make a buck off of patients paying out of pocket. The two predominant scenarios I've seen are (1) desperate parents willing to do and pay whatever ever they have to help their kid even if it isn't necessary or demonstrably helpful (thereby being taken advantage of by the unscrupulous) and (2) patients looking to buy a diagnosis for some reason (e.g., accommodations on high stakes testing.
Can't you provide non-stimulant medication?Too much to gain for malingerers who want highly addictive stimulant medication.
Of course. But the typical patient comes in with I tried my friends Adderall and it worked. I know I have ADHD! I won't try anything else!Can't you provide non-stimulant medication?
Also, as I mentioned in another thread, the functional outcomes for stimulants alone are very poor. If people are reporting difficulty at work/school then I would be requiring behavioral strategies along with the medication. Meaning, I would prescribe the meds only in conjunction with therapy. This also allows the therapist to monitor the medication use. If they person complains that non-stimulant meds do not work, make the stimulant medication contingent on a trial of non-stimulant along with 3 months of behavioral intervention. Of course, good luck finding someone that is willing to do CBT for ADHD that takes insurance and has a spot.
CAARS has a couple of SVTs embedded. I'd use that, along with a solid clinical interview and chart review to look for consistencies/inconsistencies
Then, of course, the question becomes: what do you conclude if the validity indicators suggest there's overreporting?
This is a topic I've spent a lot of time studying and am particularly interested in. Feel free to PM if interested in having a back-channel conversation.