Is this what therapy has become for many?

[R. Matey]

Whats "all the difference???"

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.

Also, you need to keep in mind your phrase... "in training.' Its common for supervisors not to really care to much about what is needed, efficient, discriminatory, actually translatable to a treatment plan, etc when training grad students. They arent 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.

If you want more information about the specifics of the situation feel free to DM me. I don't feel comfortable disclosing more on a public board.

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[WisNeuro]

I agree with you there though I've seen the clinical mythos more at play in psychotherapy. It's sad to see that it also extends to testing.

It's not unique to psychology or neuropsychology. You should check out the evidence base for many standard peds recommendations. Or nutrition stuff. Plenty to go around.

 

[ExecutiveDysfunction]

I'm not saying that there aren't neuropsychs using tests to diagnose ADHD, I'm just saying that they are not using a solid evidence base to do so in some situations. Unfortunately, we still have a lot of neuropsych clinical myths that persist. One of the reasons one of my first didactics goes over some of these clinical lore issues and explores the evidence base behind them.

Would you feel comfortable sharing those myths? I’m interested to hear them


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[WisNeuro]

Would you feel comfortable sharing those myths? I’m interested to hear them


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Dodrill had a couple of good articles about this a while back, and Roper has published a little more recently, those would be good places to start. Fairly simple things such as variance within an individual profile, >1SD strength and weakness differences is the rule, not the exception, as opposed to people using those variances as evidence for decline. Or assuming that overall IQ and memory should be the same, when they, at best, have a .5 correlation. Things like that.

 

[AcronymAllergy]

Also, it's important to keep in mind that if the testing is required for accommodations, it can certainly be administered. It's just that using the data to actually make the ADHD diagnosis (as opposed to ruling-out other things, such as LD perhaps) is scientifically-questionable, and requiring the testing for the diagnosis (again, when your rule-outs don't require it) is inefficient. And perhaps for some of these reasons (and lack of medical necessity), psychoed evals are typically paid for out-of-pocket.

 

[R. Matey]

Also, it's important to keep in mind that if the testing is required for accommodations, it can certainly be administered. It's just that using the data to actually make the ADHD diagnosis (as opposed to ruling-out other things, such as LD perhaps) is scientifically-questionable, and requiring the testing for the diagnosis (again, when your rule-outs don't require it) is inefficient. And perhaps for some of these reasons (and lack of medical necessity), psychoed evals are typically paid for out-of-pocket.

Do you mind putting out a few citations on this issue? I’m not trying to be contentious, but some of this is news to me.

 

[erg923]

Do you mind putting out a few citations on this issue? I’m not trying to be contentious, but some of this is news to me.

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. This might also tie back to what I mentioned in my PM to you? There is a difference between clinically significant vs statistically 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).

References

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.

 

[AcronymAllergy]

I don't have many immediately handy, but Nigg has done a lot of work in the area. Seidman also wrote a review, although it's 14 years old at this point (2006: neuropsychological functioning in people with ADHD across the lifespan). Koziol & Stevens (2012) review the issue of neuropsych assessment in the diagnosis of ADHD specifically (neuropsychological assessment and the paradox of ADHD). Many of the studies that find lower scores in ADHD are also making comparisons relative to controls, rather than to other psychiatric groups. Plus, ADHD is thought of as a relatively heterogeneous condition. And not at all to seem dismissive, but there are also the DSM criteria themselves.

At the end of the day, for the diagnosis of ADHD specifically, neuropsych testing's "bang for the buck" is very, very limited when compared with other, potentially shorter and cheaper, assessment methods (i.e,. clinical interview, collateral report, observation).

Edit: also, yes, I should've clarified that psychoed evals being an out-of-pocket expense is generally in the context of them being performed outside of schools. I only see adults, so in pretty much all of my patients, they would likely need to pay for the eval themselves.

 

[cara susanna]

When I was on internship, I had a neuropsychologist supervisor who told me that neuropsych at our facility would outright refuse adult ADHD referrals. And this site had a pretty strong reputation for neuropsych.

 

[R. Matey]

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. This might also tie back to what I mentioned in my PM to you? 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.

Thanks! I responded to you.

 

[manwelio]

IME: Some (many?) psychiatrists and psychologists seem scared or ignorant to diagnose ADHD. This is baffling to me cause it is such a ubiquitous dx and really isn't all that hard to rule-out if you just...try. It makes me wonder what they teach about this disorder in psychiatric residency programs? Same with MDD vs Bipolar disorder? That has got to be bread and butter stuff for a psychiatrist, I mean, come on? Have they had manic episode or not? Spend some time. Get an MDQ...or something. There is such as thing as too much data and too much input/opinion in order to be helpful/render treatment.

I know at least three people who spent 5-15+ years getting told they had depression, just depression, by therapists and prescribing psychiatrists who would meet with them for 15 minutes to ask how they're "feeling" on Wellbutrin.

Meanwhile in my daily life interactions with them I had one dissociate on me during an intensely manic episode and not remember his children or marriage, then they spent two weeks avoiding everyone they knew. Another had terrible emotion regulation, was not good at making financial decisions, went into bad depressions from drug use, all of which lost him his job. I had another acquaintance in the middle of a paranoia episode say they thought they were being followed by people (honestly not unlike scenes from A Beautiful Mind after all) after losing two different jobs in two years because they couldn't concentrate and had made bad financial and relationship decisions. And then yet another would post series of 3 am freak-out Facebook messages about everything wrong with themselves—public posts—about their mistakes, failures, problems, and lack of fitness for the world that concerned everyone who knew them and how they needed to reinvent themselves to be a better person.

Every single one of them had markers for developmental problems with parents while growing up. Each had severe symptoms that went beyond your average depression if you asked them to talk about it. And all of them were eventually diagnosed only after severe episodes cost them all dearly: rapid cycling bipolar disorder, bipolar II, schizophrenia, and borderline personality disorder respectively.

 

[Childdoconeday]

I had an interesting moment the other day while working with an acute patient at my hospital. This particular patient has a longitudinal history of debilitating schizophrenia even whilst medicated, and most, if not all of his family has left him high and dry. Consequently, all he has essentially is my hospital and his outpatient team and therapist. We had a tele-psych video conference with his outpatient therapist, who is a LISW, and she wanted to do a “therapy” session with him. I got to see this “therapy” session as I had to be in the room to aid in using the video equipment.


What this session essentially amounted to was her going through an ISP and them just talking about if goals had been met or not. That was it. No actual intervention. No actual therapy. There were many moments where there was legitimate therapeutic grist for the mill (as one of my old supervisors use to call them), and she literally missed all of them and was just a robot going through a checklist. I almost wanted to commandeer the session, but felt that would have been a bit too cluster b of me in that moment.


I guess what I’m wondering is… is this what therapy has become for folks in this community mental health centers? Checklists of ISPs? It brought me back to when I trained at one and I remember that’s all they really cared about, not actually doing real work. And I know often these folks will be intermittent in their session attendance, or only attend one session, but I was trained that even in those circumstances, legitimate therapeutic work can occur with benefit. It also highlighted to me (at least superficially) the differences between doctoral level services and what I have seen a lot of master’s level folks provide (not all, but many). At the end of it I just felt bad for this man, as he had been looking forward to the meeting (he’s been stuck on a unit since March because of COVID), and he just appeared let down and deflated subsequent to their session. Anyways….rant over.

My friend at Kaiser said that therapy is very similar to this. Therapists are overburdened and focused on reviewing symptoms and exploring where the pt is with regards to working on the established treatment goals.