Neuropsychological Testing for ADHD Diagnosis

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by cara susanna, Feb 1, 2019.

  1. cara susanna

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    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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  2. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    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.
     
  3. OP
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    cara susanna

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    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!
     
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  4. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    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.
     
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  5. Justanothergrad

    Justanothergrad Counseling Psychologist
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    +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.
     
  6. erg923

    erg923 Psychologist, Centene Corp
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    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).
     
  7. spagetti_jones

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    What is your "minimally defensible" ADHD test protocol?
     
  8. LadyHalcyon

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    Thoughts about the CCT?
     
  9. WisNeuro

    WisNeuro Board Certified Neuropsychologist
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    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
     
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  10. erg923

    erg923 Psychologist, Centene Corp
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    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.
     
  11. DynamicDidactic

    DynamicDidactic Ass of Prof
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    It will likely differ by age.
     
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  12. LadyHalcyon

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    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.
     
  13. erg923

    erg923 Psychologist, Centene Corp
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    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.
     
  14. LadyHalcyon

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    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.
     
  15. erg923

    erg923 Psychologist, Centene Corp
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    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."
     
    #15 erg923, Feb 1, 2019
    Last edited: Feb 1, 2019
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  16. LadyHalcyon

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    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.
     
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  17. erg923

    erg923 Psychologist, Centene Corp
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    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.
     
  18. LadyHalcyon

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    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?
     
  19. erg923

    erg923 Psychologist, Centene Corp
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    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.
     
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  20. LadyHalcyon

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    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?
     
  21. Pragma

    Pragma Neuropsychologist
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    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.
     
  22. Fan_of_Meehl

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

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    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.
     
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  24. BubuB

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    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.
     
  25. PSYDNEUROGUY

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    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.
     
  26. erg923

    erg923 Psychologist, Centene Corp
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    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.
     
    #26 erg923, Feb 11, 2019
    Last edited: Feb 11, 2019
  27. erg923

    erg923 Psychologist, Centene Corp
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    Is this based on large N data, complete with neuroimaging?

    Need testing for that?
     
    #27 erg923, Feb 11, 2019
    Last edited: Feb 11, 2019
  28. PSYDNEUROGUY

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    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 :p

    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.
     
  29. erg923

    erg923 Psychologist, Centene Corp
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    Bad science. This is pervasive within the field (as well as others), unfortunately.
     
  30. PSYDNEUROGUY

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    Could you specify what you mean? I am curious.
     
  31. erg923

    erg923 Psychologist, Centene Corp
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    Sure. See below.


    And also, repetition of what people in authority have told you....as this is science/fact.
     
    #31 erg923, Feb 11, 2019
    Last edited: Feb 11, 2019
  32. PSYDNEUROGUY

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    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.
     
  33. erg923

    erg923 Psychologist, Centene Corp
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    I don't think what we know about ADHD so far would justify such a statement.

    Read the NIMH MTA studies.
     
    #33 erg923, Feb 11, 2019
    Last edited: Feb 12, 2019

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