Neuropsychological Testing for ADHD Diagnosis

[cara susanna]

Hi all,

Does anyone have any specific articles or references supporting that neuropsych testing is not necessary for an ADHD diagnosis? If so, could you please link or share them with me?

Thanks!

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[WisNeuro]

I'll look around, but the most important piece you can get is from your regional insurers LCD materials. Pretty much universally they will clearly state that they will not reimburse neuropsych testing codes for ADHD diagnoses.

 

[cara susanna]

Thanks. One thing I remember reading on here is that there's no specific neuropsych testing profile associated with ADHD. A source for that statement would be extremely helpful!

 

[WisNeuro]

Thanks. One thing I remember reading on here is that there's no specific neuropsych testing profile associated with ADHD. A source for that statement would be extremely helpful!

It's generally from the larger body of work that shows that while we may see some differences between groups in large n studies, the variability within the ADHD population is great that the sens/spec at the individual level is quite terrible for most neuropsych indicators. Neuropsych testing is warranted if you need to rule out another neurological condition, or if they need psychoed testing for an IEP or to rule out LD.

If you're looking, check out Robb Mapou's stuff, he may have some recent articles to this point.

 

[Justanothergrad]

+1 to what WisNeuro said

There are several meta-analyses out there showing the magnitude of difference across various WAIS (and other cognitive measure) subtest or index. ADHD is typically lower, but that doesn't offer a great deal of diagnostic aid. At most it's a medium effect size and often closer to small when looking at individual tests. What that translates into with actual score differences (and understanding the typical scatter which appears) makes folks not confident to interpret a specific profile as indicative.

 

[erg923]

Tests that discriminate between people with ADHD and same-age peers from the population include measures of sustained and divided attention, working memory, verbal fluency, complex information processing speed, response inhibition, and verbal list learning (Schwean & Saklofske, 2005; Woods, Lovejoy, and Ball, 2002). Unfortunately, when we compare people with and without ADHD, the mean performance difference on such tests is only about 0.6 standard deviations (Frazier, Demaree, & Youngstrom, 2004), which means that the distributions of scores in the two groups are mostly overlapping.

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 very much (Goldstein & Kennemer, 2009).

 

[LadyHalcyon]

Thoughts about the CCT?

 

[WisNeuro]

Thoughts about the CCT?

It's a fine instrument, but there are a boatload of reasons a child can be low on it that are not ADHD, low specificity

 

[erg923]

Thoughts about the CCT?

I guess my issue has always been: attention problems do not mean adhd. ADHD diagnostic criteria not not include/require actually having deficits in sustained attention. So, im not sure how this is very useful.

 

[DynamicDidactic]

What is your "minimally defensible" ADHD test protocol?

It will likely differ by age.

 

[LadyHalcyon]

I guess my issue has always been: attention problems do not mean adhd. ADHD diagnostic criteria not not include/require actually having deficits in sustained attention. So, im not sure how this is very useful.

I use it as a measure of executive functioning, not just for sustained attention. More specifically, as a measure of cognitive interference and sequencing skills.

 

[erg923]

I use it as a measure of executive functioning, not just for sustained attention. More specifically, as a measure of cognitive interference and sequencing skills.

I dont understand how this helps you assess the DSM criteria for the disorder...which are all patterns of behavior that occur during real world tasks.

 

[LadyHalcyon]

So, if thats bad, does that mean they have ADHD?

I dont understand how this helps you assess the DSM criteria for the disorder?

I am using Barkley's model for conceptualizing adhd. It's not the only assessment I use, and I agree the best tool is an in-depth structured interview with a strong emphasis on academic performance and collateral info, but along with the wisc/wais and other personality and behavioral assessments I also like to include the CCT to assess executive functioning through their ability to switch back and forth between colors. It also taps into processing speed and sustained attention, which is useful information.

 

[erg923]

I am using Barkley's model for conceptualizing adhd. It's not the only assessment I use, and I agree the best tool is an in-depth structured interview with a strong emphasis on academic performance and collateral info, but along with the wisc/wais and other personality and behavioral assessments I also like to include the CCT to assess executive functioning through their ability to switch back and forth between colors. It also taps into processing speed and sustained attention, which is useful information.

Fair enough. The amount of assessment needed to "make the call" varies with age and individual case circumstances. I just don't think the idea of "testing for ADHD" holds much water in terms of diagnostic specificity and treatment selection/ROI for most cases. Rather, it seems to be a clinical myth propagated by psychology training programs.

The DSM is there for a reason, diagnostic comorbidity is the rule rather than the exception with this diagnosis, and often times I think psychologists portray the whole issue as more complicated than it really is/needs to be in order to justify obscene amounts of "testing."

 

[LadyHalcyon]

Fair enough. The amount of assessment needed to "make the call" varies with age and individual case circumstances. I just don't think the idea of "testing for ADHD" holds much water in terms of diagnostic specificity and treatment selection/ROI for most cases. Rather, it seems to be a clinical myth propagated by psychology training programs.

The DSM is there for a reason, diagnostic comorbidity is the rule rather than the exception with this diagnosis, and often times I think psychologists portray the whole issue as more complicated than it really is/needs to be in order to justify obscene amounts of "testing."

I actually think testing is most important as a way to rule out other diagnoses. Depression, ptsd, anxiety etc can mimic some symptoms of adhd. Given the fact the gold standard for adhd treatment, medically speaking, is an addictive and controlled substance, I do think many family practitioners/pediatricians prefer a fairly comprehensive battery because it makes them feel more comfortable prescribing stimulants.

Sure diagnostic comorbidity is very common across the board with most diagnoses, but if I'm testing for adhd and I discover PTSD my recommendation is going to be treat the ptsd first. If the attentional deficits are still present after trauma treatment, then treat the adhd.

 

[erg923]

I actually think testing is most important as a way to rule out other diagnoses. Depression, ptsd, anxiety etc can mimic some symptoms of adhd. Given the fact the gold standard for adhd treatment, medically speaking, is an addictive and controlled substance, I do think many family practitioners/pediatricians prefer a fairly comprehensive battery because it makes them feel more comfortable prescribing stimulants.

Sure diagnostic comorbidity is very common across the board with most diagnoses, but if I'm testing for adhd and I discover PTSD my recommendation is going to be treat the ptsd first. If the attentional deficits are still present after trauma treatment, then treat the adhd.

Assess and rule out mimics. No one is arguing with that. Psychological Tests may or may not be necessary to do this, is my point, however. Rule-out depression? You need a test for that? Maybe a rating-scale in addition to your collateral? But that's not "testing" and probably "incidental to" your clinical interview session...to use CMS language.

 

[LadyHalcyon]

Assess and rule out mimics. No one is arguing with that. Psychological Tests may or may not be necessary to do this, is my point, however. Rule-out depression? You need a test for that? Maybe a rating-scale in addition to your collateral? But that's not "testing" and probably "incidental to" your clinical interview session...to use CMS language.

Sure. But research shows actuarial tools are better than clinical judgement. That being said, many measures given to rule out other disorders are extremely face valid so....

I don't necessarily disagree with your point of view. If not Adhd, what clinical question do you think requires a comprehensive battery?

 

[erg923]

I'm not sure what "comprehensive battery" is/means?

Psychological Testing is an adjunct (diagnostic usually) procedure for answering clinical questions that cant be answered without it. Again, I think this is about ROI. The testing battery is whatever is needs to be to treat the patient. No more, no less.

 

[LadyHalcyon]

I'm not sure what "comprehensive battery" is/means?

Psychological Testing is an adjunct (diagnostic usually) procedure for answering clinical questions that cant be answered without it. Again, I think this is about ROI. The testing battery is whatever is needs to be to treat the patient. No more, no less.

Right. So I guess I'm asking what situations do you think "can't be answered without it?"

Edited to add: maybe that isn't a question you can answer. Are you saying when an in-depth clinical interview doesn't provide enough information for an accurate diagnosis?

 

[Pragma]

You don’t need testing done to diagnose ADHD. It is helpful with rule-outs and complex cases. It is a behavioral diagnosis.

Would it be nice information to have for treatment planning? Sure. Is it medically necessary? No.

 

[Fan_of_Meehl]

'no answer' is probably the most inappropriately underutilized diagnosis in our field.

 

[Kadhir]

It's a fact that testing is not necessary, but requested anyways in many situations. In these cases, behavioral observations are often more valuable than quantitative data, given that the patients are often students. The testing environment more closely approximates real world challenges for them than it would for other types of referrals. When a kid couldn't stop inadvertently kicking me throughout the eval, that was diagnostic. And yes, symptom reports were consistent.

 

[BubuB]

Thanks. One thing I remember reading on here is that there's no specific neuropsych testing profile associated with ADHD. A source for that statement would be extremely helpful!

Here are some relevant articles (though this is not to discount the important discussion above):
Prevalence of cognitive deficits:
Causal heterogeneity in attention-deficit/hyperactivity disorder: do we need neuropsychologically impaired subtypes? - PubMed - NCBI
Evaluating vigilance deficits in ADHD: a meta-analysis of CPT performance. - PubMed - NCBI
Meta-analysis of intellectual and neuropsychological test performance in attention-deficit/hyperactivity disorder. - PubMed - NCBI
Differences between low and high trait impulsivity are not associated with differences in inhibitory motor control. - PubMed - NCBI

The diagnostic assessment of ADHD:
Evidence-based assessment of attention deficit hyperactivity disorder in children and adolescents. - PubMed - NCBI

I hope this is useful.

 

[PSYDNEUROGUY]

One of my practicum rotations I spent a year was in a medical school's neuropsychology division where I mostly saw individuals coming in with "suspected ADHD." The supervisor specializes in ADHD and really emphasized testing as yet another means in addition to the gold standard of interviewing and collateral records and information. He conceptualized ADHD as a disorder typically affecting the right hemisphere with distinct performance deficits in sustained attention, alternating attention, EF, working memory, verbal memory, with deficits in fine sensorimotor performance. I know when I spoke to other supervisors over the years, they would be floored by this concept, especially when individuals coming in are in their 20's and 30's. However, I would say most of the people I tested I would diagnose with some type of mood disorder rather than ADHD; BP1 and BP2 were very typical. Some would argue that a 20-year-old isn't going to magically have ADHD as it is a neurodevelopmental disorder where these behavioral deficits are apparent earlier in life...which is true, but many people will go undiagnosed, untreated, etc. Notwithstanding that, but many people may not even think they had ADHD in their younger years as the "demand characteristics of their lives didn't surpass the available coping skills they had to contend with their environment; it would later be in college where they noticed these deficiencies.

 

[erg923]

." The supervisor specializes in ADHD and really emphasized testing as yet another means in addition to the gold standard of interviewing and collateral records and information.

Does this "approach" have any data regarding differential outcomes? As opposed to, your know, using the DSM criteria?

I am not a neuroscientist....I am just trying to do what gives us the best results/outcomes.

 

[erg923]

He conceptualized ADHD as a disorder typically affecting the right hemisphere with distinct performance deficits in sustained attention, alternating attention, EF, working memory, verbal memory, with deficits in fine sensorimotor performance.

Is this based on large N data, complete with neuroimaging?

However, I would say most of the people I tested I would diagnose with some type of mood disorder rather than ADHD; BP1 and BP2 were very typical.

Need testing for that?

 

[PSYDNEUROGUY]

So...just to reiterate, I am paraphrasing my supervisor's approach and what he taught us. As far as any substantial data that confirms this approach, as I am sure you are alluding to is variable and lacks supporting evidence in the literature to the best of my knowledge. Perhaps I am wrong, perhaps if I had the time I can comb through the data and get back to you, but alas, I have other readings to prepare for 😛

I remember pulling articles a while back (2018) on this when I was first introduced to this conceptualization, but I do not have a databank of articles on hand to furnish.

 

[erg923]

So...just to reiterate, I am paraphrasing my supervisor's approach and what he taught us.

Bad science. This is pervasive within the field (as well as others), unfortunately.

 

[PSYDNEUROGUY]

Bad science. This is pervasive within the field (as well as others), unfortunately.

Could you specify what you mean? I am curious.

 

[erg923]

Could you specify what you mean? I am curious.

Sure. See below.

The supervisor specializes in ADHD and really emphasized testing as yet another means in addition to the gold standard of interviewing and collateral records and information. He conceptualized ADHD as a disorder typically affecting the right hemisphere with distinct performance deficits in sustained attention, alternating attention, EF, working memory, verbal memory, with deficits in fine sensorimotor performance.

So...just to reiterate, I am paraphrasing my supervisor's approach and what he taught us.

And also, repetition of what people in authority have told you....as this is science/fact.

 

[PSYDNEUROGUY]

Ah, I see. So that concept of it being a "right-hemispheric disorder" with the aforementioned cognitive processes lack validity? At some point, I will have to return back to that literature.

 

[erg923]

Ah, I see. So that concept of it being a "right-hemispheric disorder" with the aforementioned cognitive processes lack validity? At some point, I will have to return back to that literature.

I don't think what we know about ADHD so far would justify such a statement.

Read the NIMH MTA studies.

 

[cara susanna]

Revisiting this topic because I still feel very confused about it.

Do you think that it's necessary or helpful to include tests of executive functioning in an ADHD assessment? I have recently had other psychologists, including neuropsychologists, recommend it but... see earlier on this thread.

 

[WisNeuro]

Not really, unless it is in the context of a larger assessment looking at more than just ADHD. It is more useful to find specific examples of what they are having trouble with in real life, than to see how well they can do Trails B in your office. More bang for your buck, as it were. Opinions differ. If people are interested, Robb Mapou has a good book for ADHD in adults and such.

 

[erg923]

Revisiting this topic because I still feel very confused about it.

Do you think that it's necessary or helpful to include tests of executive functioning in an ADHD assessment? I have recently had other psychologists, including neuropsychologists, recommend it but... see earlier on this thread.

If that can be translated to changing the typical treatment/treatment plan for this disorder..,.then sure. But, generally, no. Ecological validity issues and all. Treatment is generally gonna be stimulant and maybe some fam and individual therapy. More information doesn't necessarily change the treatment selection or the overall outcome. And I would bet, many times it gets lost in the mix anyway?

That said, a BRIEF might be useful. But WCST, TOL, DKEFS, NESPY subtests, Trails? Na. Would probably just muddy things up.

 

[PsyDr]

The American Academy of Pediatrics just published new guidelines in conjunction with the CDC. Neuropsych testing was deemed to not be supported for garden variety stuff. Only for complicated differentials.

 

[cara susanna]

The issue is that our psychiatrists won't prescribe stimulants without psych testing confirming a diagnosis. So this is more of a question of yes/no to ADHD vs. specific treatment planning.

I'm reading articles and it sounds like poor peformance on tests of EF is a good predictor of ADHD but doesn't exclude diagnosis.

The American Academy of Pediatrics just published new guidelines in conjunction with the CDC. Neuropsych testing was deemed to not be supported for garden variety stuff. Only for complicated differentials.

Got a link? Also, can this be applied to adults?

 

[erg923]

The issue is that our psychiatrists won't prescribe stimulants without psych testing confirming a diagnosis. So this is more of a question of yes/no to ADHD vs. specific treatment planning.

I'm reading articles and it sounds like poor peformance on tests of EF is a good predictor of ADHD but doesn't exclude diagnosis.



Got a link? Also, can this be applied to adults?

Wait? So, if they meet all the criteria and developmental history but don't have some documented deficit on some random attention or EF test, they just ignore all the rest of the evidence and refuse to treat?

Just because other people suck at their jobs or keeping up with literature doesn't mean we should waste time and money and ignore currently accepted understanding of the disorder. Perhaps an in-service for the psychiatry service at your VA?

 

[cara susanna]

Wait? So, if they meet all the criteria and developmental history but don't have some documented deficit on some random attention or EF test, they just ignore all the rest of the evidence and refuse to treat?

Just because other people suck at their jobs or keeping up with literature doesn't mean we should waste time and money and ignore currently accpted understanding of the disorder. Perhaps an in-service for the psychiatry service at your VA?

Well, it's our job (as the assessor) to say if they have it or not. But they won't prescribe meds unless someone goes through the assessment first. That's why it's important to me that I know how to properly assess for it, including the role of psych testing.

 

[erg923]

Well, it's our job (as the assessor) to say if they have it or not. But they won't prescribe meds unless someone goes through the assessment first. That's why it's important to me that I know how to properly assess for it, including the role of psych testing.

Psychiatrists are "assessors" too.

 

[cara susanna]

Psychiatrists are "assessors" too.

Lol... yeah, in theory. Not really how it works here.

 

[erg923]

Lol... yeah, in theory. Not really how it works here.

Ok. Its seems they are admitting that they dont know how to assess the disorder, but then they want to tell you how to assess the disorder???

I would push back.

 

[cara susanna]

Ok. Its seems they are admitting that they dont know how to assess the disorder, but then they want to tell you how to assess the disorder???

I would push back.

They aren't really telling us how, although that was an issue once. We developed a battery based on recommendations from neuropsych, but recently had a presentation that made it sound like measuring executive functioning is very important. Hence my confusion.

 

[Fan_of_Meehl]

Lol... yeah, in theory. Not really how it works here.

I totally agree. If no specialized testing adds to the diagnostic determination, then I think the prescribing provider should make the call and choose to prescribe or not prescribe...no psychologist necessary. However, we also have an unwritten rule at our VA that prescribing providers are somehow not responsible for engaging in actual differential dx or interviewing. It's frustrating.

 

[Fan_of_Meehl]

Well, it's our job (as the assessor) to say if they have it or not. But they won't prescribe meds unless someone goes through the assessment first. That's why it's important to me that I know how to properly assess for it, including the role of psych testing.

It's basically their way of shirking their responsibility of 'making the call' diagnostically and shifting this responsibility over to another provider (psychologist), in my cynical opinion.

 

[erg923]

They aren't really telling us how, although that was an issue once. We developed a battery based on recommendations from neuropsych, but recently had a presentation that made it sound like measuring executive functioning is very important. Hence my confusion.

But they are. "If you don't do this/show me evidence of this...I don't buy it"...is what they are saying. No?

And, very important for...what? Would be my question.

It's NOT in the DSM criteria (and its not a diagnostically discriminate feature). And it generally wont change treatment selection--Stimulant and (maybe) therapy.

Many things can be "interesting" to psychologists. That doesn't mean they are necessary or mean all that much in the grand scheme of treatment.

 

[cara susanna]

Very important for...what? Would be my question.

That's not in the DSM criteria. And its generally wont change treatment selection--Stimulant and (maybe) therapy.

Yeah, the argument here is that the DSM criteria sucks. I think the presentation was based off of Barkley's conceptualization.

 

[Fan_of_Meehl]

Yeah, the argument here is that the DSM criteria sucks. I think the presentation was based off of Barkley's conceptualization.

In the modal mental health outpatient at VA, it seems the main issue would be with the forest of commonly presenting comorbidities/issues like clinical depression, PTSD, sleep apnea, substance abuse, personality disorders, symptom overreporting (either for $$$ or a dopamine push). Any thorough evaluative process would have to rule in/out all of these other contributors to putative ADHD symptoms and likely extend over several sessions.

At my VA, ADHD 'evals' basically break down into the following scenario:

Veteran wants access to a stimulant to 'treat his ADHD.' Psychiatry won't write script until psychology 'assesses' and diagnoses ADHD (thus transferring responsibility for making the dx and decision to prescribe stimulant from psychiatrist to psychologist). Psychology almost always says 'yes' to ADHD dx...vet gets meds. Rinse and repeat.

 

[cara susanna]

In the modal mental health outpatient at VA, it seems the main issue would be with the forest of commonly presenting comorbidities/issues like clinical depression, PTSD, sleep apnea, substance abuse, personality disorders, symptom overreporting (either for $$$ or a dopamine push). Any thorough evaluative process would have to rule in/out all of these other contributors to putative ADHD symptoms and likely extend over several sessions.

At my VA, ADHD 'evals' basically break down into the following scenario:

Veteran wants access to a stimulant to 'treat his ADHD.' Psychiatry won't write script until psychology 'assesses' and diagnoses ADHD (thus transferring responsibility for making the dx and decision to prescribe stimulant from psychiatrist to psychologist). Psychology almost always says 'yes' to ADHD dx...vet gets meds. Rinse and repeat.

Pretty much the same procedure here, except psychology often says "no" here. Can I ask what battery the psychologists at your VA use?

 

[Fan_of_Meehl]

Pretty much the same procedure here, except psychology often says "no" here. Can I ask what battery the psychologists at your VA use?

There's no real 'battery' and we have a psychologist (who isn't a neuropsychologist) who sees them and does a clinical interview, the Conners Continuous Performance Test (on computer), and gives a Personality Assessment Inventory.

But, the hilarious thing is that--even when the veteran (on the first go-round) bombs the test due to minimal effort, the psychologist just gives feedback to the veteran and 'tests him again' on the Conners a week or so later (so I suppose the veteran knows not to 'bomb' the test 'too badly' so as to trigger measures of effort). At the end of the process, the vet gets his stimulants. I think that the psychiatrist/psychologists just want some 'face valid' 'cover' for the decision to fill the script (at least well enough to satisfy the clinically ignorant administrator/politician types who don't know any better) and this song and dance (ritual?) seems to serve that function.