Master’s level clinicians and assessments

[Doctor Eliza]

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Instead of screaming into the void, I thought I’d post here. On a local fb therapists page, an LPC (graduated 3 yrs ago) posted that she was recently “trained” in ADHD assessment and now is offering assessments and reports at her (cash) practice. I wish I could say this was the only post like this I’ve seen. The LPCs and MSWs around here are offering adhd and ASD assessments like crazy. And typically touting their “lived experience” and being “neurodiversity affirming.”

I was very close to asking her how she was “trained” but idk how to post an answer anonymously on FB. I try to educate my patients seeking assessments that they should not go to these practitioners, but other than that, what can be done?

I don’t even offer formal assessments anymore but it makes me so angry that there is no quality control out there!

What do you great minds of SDN think?

 

[WisNeuro]

Really depends on jurisdictional statutes and such. In my case, I just try to point out how the evals deviate from local statutes/standards of care/etc, to make board complaints and/or civil litigation easier. In one such case, a midlevel had their license taken away for not conforming to local statutes. Don't dive into the pool if you don't know how to swim.

 

[Doctor Eliza]

Oh that’s interesting. The over-confidence of some of these folks is astounding. Guess they needed to go to a doc program to have their self-confidence beaten out of them! 😂

Also we both have been on SDN 15+ years! Wow!

 

[WisNeuro]

Oh that’s interesting. The over-confidence of some of these folks is astounding. Guess they needed to go to a doc program to have their self-confidence beaten out of them! 😂

Also we both have been on SDN 15+ years! Wow!

Or at least now hot to check their local statutes for practice guidelines!

And, yeah, we're Old Guard.

 

[AcronymAllergy]

I guess it depends on how they're defining "assessment." I honestly wouldn't mind masters-level providers helping pick up some of the (adult) ADHD slack if it consisted of an adequately thorough eval without overreliance on non-empirically supported data.

Autism evals, not so much. Those, IMO, are more complicated and nuanced, and require a more in-depth understanding of neurodevelopment and psychopathology (and broader access to actual testing).

 

[PsyDr]

Or at least now hot to check their local statutes for practice guidelines!

And, yeah, we're Old Guard.

Sanman has you beat by a decade.

 

[WisNeuro]

Sanman has you beat by a decade.

Yeah, but he's the oldest, whitest guy I know. He was there swinging the hammer to scare Little Albert.

 

[Sanman]

Sanman has you beat by a decade.

Yeah, but he's the oldest, whitest guy I know. He was there swinging the hammer to scare Little Albert.

Not sure how many posters are older than I am given that SDN started in 1999.

 

[cara susanna]

Yeah, but he's the oldest, whitest guy I know. He was there swinging the hammer to scare Little Albert.

Phobia trigger or not, that rat's probably long dead by now.

 

[R. Matey]

I guess it depends on how they're defining "assessment." I honestly wouldn't mind masters-level providers helping pick up some of the (adult) ADHD slack if it consisted of an adequately thorough eval without overreliance on non-empirically supported data.

The problem is that it doesn't. Many, many of the master's level ADHD evaluations that I have seen are a an ASRS plus an unstructured interview. No informant data, no considerations of comorbidities (psychiatric or otherwise), etc.

 

[AcronymAllergy]

The problem is that it doesn't. Many, many of the master's level ADHD evaluations that I have seen are a an ASRS plus an unstructured interview. No informant data, no considerations of comorbidities (psychiatric or otherwise), etc.

Exactly, and that's the rub. Although I'd have the same problem with a doctoral-level provider performing a subpar evaluation like that.

 

[PsyDr]

If history has taught us nothing, it's that there will be ZERO backlash from the increase of stimulant prescriptions.


😉

 

[Sanman]

Exactly, and that's the rub. Although I'd have the same problem with a doctoral-level provider performing a subpar evaluation like that.

The problem is that they are a pain to do properly and easy money if done poorly.

 

[WisNeuro]

The problem is that they are a pain to do properly and easy money if done poorly.

What do you mean? I definitely need to do a full WAIS, WMS, MMPI, DKEFS, Rorschach, and a gazillion other measures to properly assess ADHD! Here's my invoice for $3000 and here's your templated report that will almost assuredly diagnose ADHD, regardless of the test findings.

 

[R. Matey]

The problem is that they are a pain to do properly and easy money if done poorly.

I think it's more telling people no is the pain.

 

[Sanman]

I think it's more telling people no is the pain.

When I was doing them, proper collateral info was the most difficult. It was not unheard to go observe a kid in their classroom environment to ensure the behavior actually existed in more than one environment. How many folks are doing that today? Adult ADHD is even more difficult as you technically need historical evidence from childhood. Saying no is a part of it. Saying no and that your school just lacks resources and has too many kids in a class is part of the bigger picture.

 

[cara susanna]

When I was doing them, proper collaterall info was the most difficult. It was not unheard to go observe a kid in their classroom environment to ensure the behavior actually existed in more than one environment. How many folks are doing that today? Adult ADHD is even more difficult as you technically need historical evidence from childhood. Saying no is a part of it. Saying no and that your school just lacks resources and has too many kids in a class is part of the bigger picture.

I honestly believe that there is no good way to diagnose ADHD in adulthood for that reason. You're relying on self-report or collateral from years ago. Almost all of my conclusions in ADHD assessments are: I can't rule it in, but I can't rule it out, either.

 

[R. Matey]

I honestly believe that there is no good way to diagnose ADHD in adulthood for that reason. You're relying on self-report or collateral from years ago. Almost all of my conclusions in ADHD assessments are: I can't rule it in, but I can't rule it out, either.

I don't think it's impossible. Any good adult ADHD evaluation is inductive. It starts with a gathering complaints regarding inattention/problems with concentration (most common complaint in adulthood) and ruling out alternate explanations. What follow is a developmental interview, multiple screeners (I've used the Conners/WURS/BAARS; I also include an EF screener), and informant data (interview plus screeners). The current recommendation in the forthcoming Adult ADHD guidelines from ABSARD will likely emphasize the current symptoms plus any evidence of childhood impairment (see here). There's debate in the neuropsychology community about whether tests are necessary. Some people think that they can be useful in detecting "edge cases" (see here and here), others think it the additional 2% or so of variance in prediction isn't really worth it (see here and here).

When I was doing them, proper collaterall info was the most difficult. It was not unheard to go observe a kid in their classroom environment to ensure the behavior actually existed in more than one environment. How many folks are doing that today? Adult ADHD is even more difficult as you technically need historical evidence from childhood. Saying no is a part of it. Saying no and that your school just lacks resources and has too many kids in a class is part of the bigger picture.

The current DSM criteria are several symptoms before age 12 (not that they meet criteria for ADHD in childhood). It also does not necessarily need to be restricted to the academic environment or just emphasize inattentive symptoms. Without giving the ball away on a public board, I would expect/need to see evidence of impairment in other areas aside from academics in order for me to feel remotely confident about ADHD.

All that said, I do think the criteria for adult ADHD are very unclear for adults and should be revised to include specific language about clinically significant impairment in adulthood rather than just sidelining the impairment issue to criterion D (especially since it is the oft-cited bulwark against false positives). Everyone loses things, everyone has interrupted someone, everyone fails to finish things they start. These aren't ADHD.

 

[cara susanna]

I don't think it's impossible. Any good adult ADHD evaluation is inductive. It starts with a gathering complaints regarding inattention/problems with concentration (most common complaint in adulthood) and ruling out alternate explanations. What follow is a developmental interview, multiple screeners (I've used the Conners/WURS/BAARS; I also include an EF screener), and informant data (interview plus screeners). The current recommendation in the forthcoming Adult ADHD guidelines from ABSARD will likely emphasize the current symptoms plus any evidence of childhood impairment (see here). There's debate in the neuropsychology community about whether tests are necessary. Some people think that they can be useful in detecting "edge cases" (see here and here), others think it the additional 2% or so of variance in prediction isn't really worth it (see here and here).

Yes, I know all that, but it's still all clouded by some degree of uncertainty. We can assess adult symptoms easily, but childhood is the fly in the ointment. Unless they had a diagnosis of ADHD in childhood, but that isn't true of most of the patients I've assessed.

 

[Sanman]

I don't think it's impossible. Any good adult ADHD evaluation is inductive. It starts with a gathering complaints regarding inattention/problems with concentration (most common complaint in adulthood) and ruling out alternate explanations. What follow is a developmental interview, multiple screeners (I've used the Conners/WURS/BAARS; I also include an EF screener), and informant data (interview plus screeners). The current recommendation in the forthcoming Adult ADHD guidelines from ABSARD will likely emphasize the current symptoms plus any evidence of childhood impairment (see here). There's debate in the neuropsychology community about whether tests are necessary. Some people think that they can be useful in detecting "edge cases" (see here and here), others think it the additional 2% or so of variance in prediction isn't really worth it (see here and here).



The current DSM criteria are several symptoms before age 12 (not that they meet criteria for ADHD in childhood). It also does not necessarily need to be restricted to the academic environment or just emphasize inattentive symptoms. Without giving the ball away on a public board, I would expect/need to see evidence of impairment in other areas aside from academics in order for me to feel remotely confident about ADHD.

All that said, I do think the criteria for adult ADHD are very unclear for adults and should be revised to include specific language about clinically significant impairment in adulthood rather than just sidelining the impairment issue to criterion D (especially since it is the oft-cited bulwark against false positives). Everyone loses things, everyone has interrupted someone, everyone fails to finish things they start. These aren't ADHD.

Agreed and it is not necessarily about a childhood diagnosis of ADHD or only academic impairment. However, these are easily accesible evidence of symptoms prior to age 12. The issue with adult ADHD is lack of collateral generally on folks who frequently show up with secondary gain issues. Proper developmental interviews are time consuming. Easier to rubber stamp a Connors.

 

[R. Matey]

Yes, I know all that, but it's still all clouded by some degree of uncertainty. We can assess adult symptoms easily, but childhood is the fly in the ointment. Unless they had a diagnosis of ADHD in childhood, but that isn't true of most of the patients I've assessed.

I mean, uncertainty is inherent to the enterprise. In PTSD, the argument for expanding criterion A would be to reduce the number of supposed false negatives, no? Doesn't that imply there should be less certainty in that criterion? Reports of childhood symptoms for adults could be biased, yes, but so can parent- and teacher-report in child/adolescent evaluation of ADHD from those with other secondary gains (e.g., the hope of medicating children into compliance).

 

[cara susanna]

I mean, uncertainty is inherent to the enterprise. In PTSD, the argument for expanding criterion A would be to reduce the number of supposed false negatives, no? Doesn't that imply there should be less certainty in that criterion? Reports of childhood symptoms for adults could be biased, yes, but so can parent- and teacher-report in child/adolescent evaluation of ADHD from those with other secondary gains (e.g., the hope of medicating children into compliance).

It's more that you haven't had a chance to assess them at the time the diagnosis would have been made.

 

[R. Matey]

It's more that you haven't had a chance to assess them at the time the diagnosis would have been made.

Sure, but again, the DSM does not require someone to meet criteria for ADHD in childhood in order to be diagnosed in adulthood. There's also evidence, from the MTA, and other places that ADHD symptoms wax and wane through childhood and early adolescence.

 

[Sanman]

I mean, uncertainty is inherent to the enterprise. In PTSD, the argument for expanding criterion A would be to reduce the number of supposed false negatives, no? Doesn't that imply there should be less certainty in that criterion? Reports of childhood symptoms for adults could be biased, yes, but so can parent- and teacher-report in child/adolescent evaluation of ADHD from those with other secondary gains (e.g., the hope of medicating children into compliance).

True, but with children, a parent and teacher independently reporting symptoms is less likely to be biased. You also have the chance to independently evaluate in the moment. Then again, the risk of medicating a child should more strict than an adult requesting a drug. Academic acommodations are a bit different.

 

[aim-agm]

I honestly believe that there is no good way to diagnose ADHD in adulthood for that reason. You're relying on self-report or collateral from years ago. Almost all of my conclusions in ADHD assessments are: I can't rule it in, but I can't rule it out, either.

I would say hyperactive (or combined) presentations aren't too bad to diagnose in adults, the objective findings which are quite difficult to simulate/malinger make things a lot easier, and the differential for hyperactivity is fairly narrow.

 

[Sanman]

I would say hyperactive (or combined) presentations aren't too bad to diagnose in adults, the objective findings which are quite difficult to simulate/malinger make things a lot easier, and the differential for hyperactivity is fairly narrow.

In the general pop, I would agree. In the VA, they like to hit all the comorbidities. I had a guy complaining about subjective memory concerns and poor concentration. Diagnosed PTSD, 3 hrs sleep per night, OSA non-compliant with cpap, and had 3 cups of coffee and 5 cans of coke per day. I wish that were an anomaly.

 

[Fan_of_Meehl]

The problem is that they are a pain to do properly and easy money if done poorly.

Kind of like 'PTSD evaluations.'

 

[PsyDr]

I don't think it's impossible. Any good adult ADHD evaluation is inductive. It starts with a gathering complaints regarding inattention/problems with concentration (most common complaint in adulthood) and ruling out alternate explanations. What follow is a developmental interview, multiple screeners (I've used the Conners/WURS/BAARS; I also include an EF screener), and informant data (interview plus screeners). The current recommendation in the forthcoming Adult ADHD guidelines from ABSARD will likely emphasize the current symptoms plus any evidence of childhood impairment (see here). There's debate in the neuropsychology community about whether tests are necessary. Some people think that they can be useful in detecting "edge cases" (see here and here), others think it the additional 2% or so of variance in prediction isn't really worth it (see here and here).



The current DSM criteria are several symptoms before age 12 (not that they meet criteria for ADHD in childhood). It also does not necessarily need to be restricted to the academic environment or just emphasize inattentive symptoms. Without giving the ball away on a public board, I would expect/need to see evidence of impairment in other areas aside from academics in order for me to feel remotely confident about ADHD.

All that said, I do think the criteria for adult ADHD are very unclear for adults and should be revised to include specific language about clinically significant impairment in adulthood rather than just sidelining the impairment issue to criterion D (especially since it is the oft-cited bulwark against false positives). Everyone loses things, everyone has interrupted someone, everyone fails to finish things they start. These aren't ADHD.

You/they are leaving out the 2nd most important criterion: Criterion E.

There is substantial education required to understand WHAT has to be to ruled out. It is a mistake to avoid ruling out: low g, OSA/CSA, epilepsies/neuro disorders, cardiac disorders as required by the AACP, Axis I disorders, LDs, language fluencies, parenting, expectations of achievement that are disproportionate to ability, etc.

 

[Fan_of_Meehl]

It's more that you haven't had a chance to assess them at the time the diagnosis would have been made.

This is one of the problems that I am increasingly having with the categorical diagnostic label / 'latent disease model' approach.

What is the question?

"Does Mr. Smith *have ADHD*?"

Are you asking me to conduct a multi-modal psychological evaluation process in order to formulate/test hypotheses regarding likely contributors to his self-reported problems with attention/concentration or hyperactivity (along with the panoply of interpersonal, occupational, emotional, physical, spiritual and financial problems that he attributes to "his ADHD")?

No, I'm asking you to give a definitive "yes" or "no" response to the question, "Does Mr. Smith 'have ADHD?'"

Let me introduce you to my problematic little friend, 'reification' and his first cousin, 'tautological/circular reasoning.'

 

[Sanman]

This is one of the problems that I am increasingly having with the categorical diagnostic label / 'latent disease model' approach.

What is the question?

"Does Mr. Smith *have ADHD*?"

Are you asking me to conduct a multi-modal psychological evaluation process in order to formulate/test hypotheses regarding likely contributors to his self-reported problems with attention/concentration or hyperactivity (along with the panoply of interpersonal, occupational, emotional, physical, spiritual and financial problems that he attributes to "his ADHD")?

No, I'm asking you to give a definitive "yes" or "no" response to the question, "Does Mr. Smith 'have ADHD?'"

Let me introduce you to my problematic little friend, 'reification' and his first cousin, 'tautological/circular reasoning.'

Still a better question than the ubiquitous "Does Mr.Smith have capacity?" Or the related but even more uneducated consult question "Is Mr. Smith competent?"

Competent to do what? This is not a yes or no question. I am not a judge. Depending on my mood, I may be your executioner though.

 

[Therapist4Chnge]

Still a better question than the ubiquitous "Does Mr.Smith have capacity?" Or the related but even more uneducated consult question "Is Mr. Smith competent?"

Competent to do what? This is not a yes or no question. I am not a judge. Depending on my mood, I may be your executioner though.

My capacity v competency grand rounds was always the most well attended talk I gave every year. Seeing how confusing the average clinician would get about this topic makes me cringe even more thinking about doctorally-trained generalists and mid-levels trying to do a wide range of assessments. Administering some self-report measures is what many thought was sufficient, so frustrating.

 

[R. Matey]

You/they are leaving out the 2nd most important criterion: Criterion E.

There is substantial education required to understand WHAT has to be to ruled out. It is a mistake to avoid ruling out: low g, OSA/CSA, epilepsies/neuro disorders, cardiac disorders as required by the AACP, Axis I disorders, LDs, language fluencies, parenting, expectations of achievement that are disproportionate to ability, etc.

Well, I did say upthread that ruling out alternative explanations (both psychiatric and otherwise) is often a feature missing from master's level evaluations. But I don't disagree, which is one of the reasons why I think psychologists/psychiatrists should be doing these evaluations.

Based on your post though, do you tend to be more in favor of neuropsych testing as a means of rule out?

 

[PsyDr]

1) Fair enough, I retract and apologize for missing that point.

2) I favor having sufficient knowledge of medical pathologies, to allow ddx. However, I believe that 85% of "real/non-LD" neuropsych cases don't need testing IF you have enough education and experience. Like any other professional practice, there is some requirement for specialized education (e.g., a local psychologist, with far superior education, is convinced that an advanced Alzheimers patient, with behavioral disinbition among everything else, has "new onset mania").

 

[aim-agm]

Still a better question than the ubiquitous "Does Mr.Smith have capacity?" Or the related but even more uneducated consult question "Is Mr. Smith competent?"

Competent to do what? This is not a yes or no question. I am not a judge. Depending on my mood, I may be your executioner though.

"I don't know about Mr. Smith, but you certainly aren't competent." - fantasy Dr. aim-agm every time they get that consult

 

[futureapppsy2]

IME, lack of good differentials is a problem in midlevel diagnosis in general.
"The patient has anxiety."
"What makes you think that?"
"They said so."
"What does anxiety look like for them?"
"They said that they're anxious.'
"Have you considered anything else that could explain this symptom?"
"They said they feel anxious."

 

[oliversacks4thewin]

"I don't know about Mr. Smith, but you certainly aren't competent." - fantasy Dr. aim-agm every time they get that consult

I'll use any excuse I can to post this video, all day, every day lol.

"Competent at what? Riding a bicycle? Woodworking? Astrophysics?"

 

[cara susanna]

I'll use any excuse I can to post this video, all day, every day lol.

"Competent at what? Riding a bicycle? Woodworking? Astrophysics?"

That video is so validating in so many ways.

 

[futureapppsy2]

That video is so validating in so many ways.

I love his one on curbsiding... "No, no, I just want you to take a few minutes to assume all legal liability for this patient!"

 

[quickpsych]

The ol' they don't know what they don't know and then their overconfidence usually boosted by their fellow midlevels who also don't know what they don't know is a growing problem.

I've noticed this a lot in organizations where the managers or higher ups are almost all LPCs or LCSWs and the number of them that think because they are in management they are experts on everything is kind of amusing TBH, but in some organizations they get in the way and cause more problems. I've noticed a concerning trend (and usually a follow the money thing), that many organizations have started just seeing LMFTs as equal to licensed psychologists (because in many states LMFTs can bill Medicare A).

But to the original context of this thread, the number of midlevels (and even "life coaches") offering their own AI built or "lived experience built" mini "assessments" for ADHD, autism, etc on platforms like Instagram is really wild.

 

[Sanman]

The ol' they don't know what they don't know and then their overconfidence usually boosted by their fellow midlevels who also don't know what they don't know is a growing problem.

I've noticed this a lot in organizations where the managers or higher ups are almost all LPCs or LCSWs and the number of them that think because they are in management they are experts on everything is kind of amusing TBH, but in some organizations they get in the way and cause more problems. I've noticed a concerning trend (and usually a follow the money thing), that many organizations have started just seeing LMFTs as equal to licensed psychologists (because in many states LMFTs can bill Medicare A).

But to the original context of this thread, the number of midlevels (and even "life coaches") offering their own AI built or "lived experience built" mini "assessments" for ADHD, autism, etc on platforms like Instagram is really wild.

I am not going to be surprised when the salaries offered to us are exactly 25 percent more than a midlevel. For context, when I started out my company was paying psychologists 50 percent more than midlevels with many openings. However, we were the only option for snf facilities at the time. Many folks mentioned companies were making little off of us but needed to offer the service and made money off the NPs. Increasingly solo private practice may be the only way to money.

 

[PsyDr]

I've witnessed multiple LPCs state that they are competent to evaluate all ages, for every condition, for every situation. They don't seem to understand the difference between "licensed to do something" and "competent to do something".

 

[oliversacks4thewin]

I've witnessed multiple LPCs state that they are competent to evaluate all ages, for every condition, for every situation. They don't seem to understand the difference between "licensed to do something" and "competent to do something".

Sounds like you're suggesting they may need a competency eval? 😆

 

[Therapist4Chnge]

Sounds like you're suggesting they may need a competency eval? 😆

Maybe, but they'll claim that they "did their own research" and according to them, they did everything right and we are wrong. When asked for proof they go, "Trust me bro!!"

 

[Sanman]

Maybe, but they'll claim that they "did their own research" and according to them, they did everything right and we are wrong. When asked for proof they go, "Trust me bro!!"

I once had a shared class with a masters level program during grad school and we were assigned groups for a research project. We split up the project into parts and each researched our own part. When providing citations for the presentation one of the masters level students in my group said "I got this information straight from the internet". You can't argue with sources like that. Also, guess who did not get an A on the project?

 

[Fan_of_Meehl]

Sounds like you're suggesting they may need a competency eval? 😆

NO ONE expects The Spanish Inquisition!