Just a bad day

[psychma]

Client unhappy with no autism dx 3 yrs ago. Went someplace else and got one for $$$$. Demanding I pay for re-evaluation. What is WRONG with adults who want an autism dx?

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[Therapist4Chnge]

It's the "new" ADHD. I'm sorry you have to navigate that mess. I purposefully do not take ADHD or Autism cases, despite have a bunch of experience with both....it's just not worth the hassle.

 

[WisNeuro]

It's the "new" ADHD. I'm sorry you have to navigate that mess. I purposefully do not take ADHD or Autism cases, despite have a bunch of experience with both....it's just not worth the hassle.

Yep, these all get referred out, and I still have a lengthy waiting list.

 

[psychma]

Hmmm

 

[Fan_of_Meehl]

Client unhappy with no autism dx 3 yrs ago. Went someplace else and got one for $$$$. Demanding I pay for re-evaluation. What is WRONG with adults who want an autism dx?

I don't know what the appropriate antonym for mental health 'stigma' would be. But we're definitely there with respect to certain diagnoses. When I was in training, we were, you know, trained to just try our best to objectively assess whether or not someone had the diagnoses based on a multi-modal approach and hypothesis testing. Nowadays, there appears to be a major third factor (off the books) which basically boils down to how much the patient wants (or doesn't want) the diagnosis and how much hassle it will be for you to defend 'not giving' them the diagnosis they want. It's an extreme 'reversed burden of proof' and it's infuriating to anyone who was scientifically trained (you can never 'prove' something 'doesn't exist'). I think it's going to have significant negative impact on the field for years to come. The literature on 'TBI' (overwhelming majority of cases involving past history of concussion) and 'PTSD' has already been corrupted by over-diagnosis and over-emphasis by clinicians who are terrified to tell a veteran 'no.' Drill down to the details of 90%+ of all the new research articles coming out claiming 'TBI causes X, TBI and Y, OMFG, what bout TBI and Z??!!' and you'll find their sample was composed of veterans with a history of concussion who 'screened positive' and were sent to a '2nd level evaluation' (basically, a team of folks asks the person to self-report on history of TBI as well as a million symptoms non-specific to TBI sequelae). It's amazing how 95% of the veterans who 'screened positive' for a history of concussion AND went through the trouble of attending a 2nd level evaluation at VA all had (or were self-reporting) SIGNIFICANT clinical symptoms of depression, anxiety, etc. Where are all the non-mental-health impaired veterans who simply had a concussion but are fine? Oh, that's right, they're screening positive but saying, 'nah, I'm good' and not showing up to a '2nd level eval' and--CRITICALLY--are self-selected out of any future 'samples' of 'mTBI' veterans. They never make it into the study population.

 

[AcronymAllergy]

I also refer out early all of these referrals, in part because I have more than enough neuropsych-focused work and you generally don't need a neuropsychologist for these. And in part because I just don't want to deal with the potential headaches afterward.

There's definitely a need for quality evals of this type. And there's definitely a segment of the MH provider population happy to provide low-quality evals to tell the patients what they want to hear rather than what may be accurate.

Edit to say: I also agree that I don't see any obligation for you to pay for a re-evaluation/second opinion.

 

[Sanman]

Client unhappy with no autism dx 3 yrs ago. Went someplace else and got one for $$$$. Demanding I pay for re-evaluation. What is WRONG with adults who want an autism dx?

Are they suing you or just showing up demanding this? If the latter, the door is over there.

 

[WisNeuro]

Are they suing you or just showing up demanding this? If the latter, the door is over there.

Patients are free to get a a second opinion from another provider. Barring gross incompetence, or practicing outside one's scope as defined by statute, there is no case.

 

[Sanman]

Patients are free to get a a second opinion from another provider. Barring gross incompetence, or practicing outside one's scope as defined by statute, there is no case.

Absolutely, still need to get a lawyer though.

 

[WisNeuro]

Absolutely, still need to get a lawyer though.

Definitely, everyone in private practice should already have one.

 

[jdawg2017]

I feel like this is implied, but I feel like a consent to treatment should now also include clear statements around no guarantee around specific diagnoses. My doctoral program training clinic stopped seeing ASD and ADHD cases because we had enough “no DX” patients go ballistic and try to tarnish our clinic’s reputation in our community. To my knowledge, nobody actually sued our clinic but they launched scorched earth word of mouth campaigns.

I feel like the pendulum of reducing mental health stigma has swung too far in the wrong direction. Nobody should actively want a neurodevelopmental diagnosis, as living with ADHD (or especially ASD) is difficult. My gut feeling is that these diagnoses give some patients who truly don’t have the diagnosis an “off ramp” to avoid the hard work of doing psychotherapy to address underlying anxiety, depression, and/or maladaptive personality traits.

 

[R. Matey]

There's definitely a need for quality evals of this type. And there's definitely a segment of the MH provider population happy to provide low-quality evals to tell the patients what they want to hear rather than what may be accurate.

I'm not a big fan of the logic behind an "ADHD/Autism evaluation." If someone is going to do them responsibility in community, the question is, "what is the evidence of dysfunction and impairment, irrespective of what a priori label you've assigned to them?" In other words, I would be shifty about someone calling themselves an ADHD evaluator and be more likely to send them to someone with appropriate training in ADHD, but does not necessarily advertise as an ADHD focused practice. Hard to find, I know.

 

[WisNeuro]

I'm not a big fan of the logic behind an "ADHD/Autism evaluation." If someone is going to do them responsibility in community, the question is, "what is the evidence of dysfunction and impairment, irrespective of what a priori label you've assigned to them?" In other words, I would be shifty about someone calling themselves an ADHD evaluator and be more likely to send them to someone with appropriate training in ADHD, but does not necessarily advertise as an ADHD focused practice. Hard to find, I know.

Most neuropsychologists can do these evaluations, with higher competence levels than the community providers who currently do them. But, the anger at no diagnosis evals, paired with fairly consistent experiences of difficulty with such patients, leads most of us to decline these. Personally, why would I take evaluations with a very high likelihood of adverse patient interactions following the eval, when I already have a lengthy waitlist of straightforward patients with an extremely low rate of post-eval difficulties? When the pay is the same?

 

[R. Matey]

Most neuropsychologists can do these evaluations, with higher competence levels than the community providers who currently do them. But, the anger at no diagnosis evals, paired with fairly consistent experiences of difficulty with such patients, leads most of us to decline these. Personally, why would I take evaluations with a very high likelihood of adverse patient interactions following the eval, when I already have a lengthy waitlist of straightforward patients with an extremely low rate of post-eval difficulties? When the pay is the same?

Yeah, I think you guys have better things to do and practically it's impossible to be completely agnostic to a label if it drives the specialty referral. For us health service folks who want to address the need though, I would think that saying "I do mental health evaluations" rather than "I do ADHD evaluations" is a better way to frame it. Yes, some people will still be mad if you tell them it's not ADHD/Autism, but at times offering a compelling alternative explanation can be helpful. That's easier to do if you frame the goals of the evaluation more broadly.

 

[cara susanna]

Our neuropsych dept (VA) just started referring autism evals out to the community

 

[AcronymAllergy]

I'm not a big fan of the logic behind an "ADHD/Autism evaluation." If someone is going to do them responsibility in community, the question is, "what is the evidence of dysfunction and impairment, irrespective of what a priori label you've assigned to them?" In other words, I would be shifty about someone calling themselves an ADHD evaluator and be more likely to send them to someone with appropriate training in ADHD, but does not necessarily advertise as an ADHD focused practice. Hard to find, I know.

I agree in a broad sense. I don't think many, if any, of us would perform an eval just to look for ADHD and/or autism. That's, of course, just the referral that comes in, based usually on statements made by the patient to the referring provider (e.g., "I took an online quiz that told me I have ADHD"), or on the referring clinician's judgment/observations/etc. But I do think evals for neurodevelopmental disorders can differ, in some ways, from many other mental health evaluations, given the potential need for and utility of things like childhood records, collateral report, etc. And, if there's requests for things like academic or other accommodations, the need for cognitive and academic testing.

That said, unless the population suddenly stops aging and developing later-life neurocognitive disorders, I don't see myself advertising ADHD/adult autism evals anytime soon. When I've done them in the past, it's usually as a favor to the referral source, and often with my office manager telling them ahead of time that we don't usually take these.

 

[psychma]

I managed to talk this person down. I do have an attorney on retainer though for these things.

 

[R. Matey]

I agree in a broad sense. I don't think many, if any, of us would perform an eval just to look for ADHD and/or autism. That's, of course, just the referral that comes in, based usually on statements made by the patient to the referring provider (e.g., "I took an online quiz that told me I have ADHD"), or on the referring clinician's judgment/observations/etc. But I do think evals for neurodevelopmental disorders can differ, in some ways, from many other mental health evaluations, given the potential need for and utility of things like childhood records, collateral report, etc. And, if there's requests for things like academic or other accommodations, the need for cognitive and academic testing.

Of course. My point is largely that if someone is billing themselves as an neurodevelopmentally focused clinician, I would be concerned about about the lens from which they are approaching the evaluation (i.e., ADHD/Autism focused, rather than psychopathology focused). The obvious problem with the former is that other forms of psychopathology are ignored in favor of the more narrowed goal of the assessment and comorbidities might be missed. That's not to say that these evaluations are not different from adult onset psychopathology or don't require different methods. As I already said, the person still needs to be trained to do the eval according to best practice.

 

[psychma]

Yeah, I think you guys have better things to do and practically it's impossible to be completely agnostic to a label if it drives the specialty referral. For us health service folks who want to address the need though, I would think that saying "I do mental health evaluations" rather than "I do ADHD evaluations" is a better way to frame it. Yes, some people will still be mad if you tell them it's not ADHD/Autism, but at times offering a compelling alternative explanation can be helpful. That's easier to do if you frame the goals of the evaluation more broadly.

I frame all of my evals as mental health. Depending on client presentation I do the PAI, daps, tsi-2, caps, scid, scid-5-pd etc

 

[Fan_of_Meehl]

Our neuropsych dept (VA) just started referring autism evals out to the community

I don't think ours ever accepted such referrals in the first place.

 

[AcronymAllergy]

I don't think ours ever accepted such referrals in the first place.

Yeah, I never accepted evals for autism. I'd screen for it if appropriate and if requested (which only ever happened maybe twice), but was very upfront that adequately assessing for and establishing an actual diagnosis was outside the scope of my evals.