Neuropsychological Testing for ADHD Diagnosis

[AcronymAllergy]

Do people with ADHD sometimes perform below expectation on EF measure? Yes. Is it diagnostically useful for ADHD? No, except (as noted above) sometimes in complex cases. Although "complex" doesn't really include differentiation of ADHD from other psychological conditions (e.g., depression, anxiety, PTSD); a thorough clinical interview is all you really "need" there. Maybe throw in a rating scale or two, and/or patient + collateral rating measures.

We (neuropsych) used to get all the ADHD evals here. A lot of it stemmed from faulty belief that our numbers added to the validity of the diagnosis. And to be fair, I understand the desire for numbers or other objective data, particularly in psychiatrically complex patients. Unfortunately, we don't have it for ADHD. We pushed back, due in no small part to our growing wait list, and these are now almost all handled by the treating MH provider.

---

Members don't see this ad.

 

[Fan_of_Meehl]

Do people with ADHD sometimes perform below expectation on EF measure? Yes. Is it diagnostically useful for ADHD? No, except (as noted above) sometimes in complex cases. Although "complex" doesn't really include differentiation of ADHD from other psychological conditions (e.g., depression, anxiety, PTSD); a thorough clinical interview is all you really "need" there. Maybe throw in a rating scale or two, and/or patient + collateral rating measures.

We (neuropsych) used to get all the ADHD evals here. A lot of it stemmed from faulty belief that our numbers added to the validity of the diagnosis. And to be fair, I understand the desire for numbers or other objective data, particularly in psychiatrically complex patients. Unfortunately, we don't have it for ADHD. We pushed back, due in no small part to our growing wait list, and these are now almost all handled by the treating MH provider.

What do you think about the idea that the prescribing provider (psychiatrist) might be in a position to decide who may be appropriate for prescription of the psychostimulant (via engaging in an actual differential diagnostic process themselves)? It just seems to me that attentional issues lie on a continuum and where--along that continuum of functioning--it is justified to give a formal diagnosis (of ADHD) and offer psychostimulant treatment and at what dose, and how long, and with what attendant adjustments, would be best determined by the prescribing provider in collaboration with the patient. That way the questions having to do with diagnostics, assessment (initial and ongoing), treatment (psychostimulant) response, and treatment (psychostimulant) adjustment could take place within the context of visits with the prescribing provider.

I realize that prescribers don't 'have a lot of time' to devote to these sorts of activities but: a) I'm not sure that's a valid reason that they shouldn't and b) I'm not sure that the commonly held assumption that therapists do have plenty of time to spare to devote to them is accurate

For example, if I'm (as I'm currently forced to due to understaffing) only able to see a veteran every 1-4 months for 'psychotherapy' 'sessions' (essentially, crisis management, suicide prevention, and mental health case management) and that veteran has primary diagnoses of severe clinical depression, severe PTSD, and alcohol use disorder (but won't see SUDS)...and, oh yeah, might have a touch of 'the ADHD,' then as I'm prioritizing how to spend my limited clinical face-time with him, I gotta say, I'm really DE-prioritizing chasing after the zebra of ADHD as a primary driver of dysfunction when we have established clinical depression, PTSD, and alcohol abuse as the major issues. I'm going to focus my time on trying to apply brief interventions (motivational interviewing, cognitive restructuring, relaxation training, problem-solving, behavioral activation) around THESE primary clinical issues and I'm quite unlikely to chase down the ADHD issue. Of course, every case is different, but in most cases there just isn't the 'treatment utility' payoff in doing so in these cases with so much psychiatric comorbidity staring me in the face and--as others have said--we want to focus on the treatable identified issues/diagnoses first and then perhaps 'treat' any residual issues potentially influenced by 'ADHD' later. Meanwhile, the veteran is pissed about not getting access to meds and complains to the patient advocate, administration, or even Congress. I'm not sure why a board certified psychiatrist making hundreds of thousands of dollars per year and who is--ostensibly--capable of and responsible for assessing/diagnosing and treating mental disorders can't independently assess/diagnose/treat ADHD with psychostimulant medication.

 

[PsyDr]

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?

I wouldn't assume pediatrics would try to opine about adults.

Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood and can profoundly affect children’s academic achievement, well-being, and social interactions. The American Academy of Pediatrics first published clinical recommendations for...

pediatrics.aappublications.org

 

[Fan_of_Meehl]

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!

Not sure if this one has been posted yet or not but it seems like a decent review of issues in the assessment of ADHD in veterans/adults

 

[psych.meout]

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.

Even if there was some instrument or battery that had good sensitivity and specificity for ADHD, it's still hinging on what the incremental validity is. Does testing add anything that you wouldn't already get from the actual standard of care (a good clinical interview, collateral data, medical record review, etc.)? Why should time and money be wasted on expensive testing when it only minimally adds to what you already have?

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.

And similar to what you previously noted, none of that differential would be helped by neuropsych testing, but providers who want to shift the burden to psychologists still want to meddle by insisting on things contrary to the literature.

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.

And then there are the physicians and NPs in clinics who will ask prac students what medications they should to give patients, including dosage.

What do you think about the idea that the prescribing provider (psychiatrist) might be in a position to decide who may be appropriate for prescription of the psychostimulant (via engaging in an actual differential diagnostic process themselves)? It just seems to me that attentional issues lie on a continuum and where--along that continuum of functioning--it is justified to give a formal diagnosis (of ADHD) and offer psychostimulant treatment and at what dose, and how long, and with what attendant adjustments, would be best determined by the prescribing provider in collaboration with the patient. That way the questions having to do with diagnostics, assessment (initial and ongoing), treatment (psychostimulant) response, and treatment (psychostimulant) adjustment could take place within the context of visits with the prescribing provider.

I realize that prescribers don't 'have a lot of time' to devote to these sorts of activities but: a) I'm not sure that's a valid reason that they shouldn't and b) I'm not sure that the commonly held assumption that therapists do have plenty of time to spare to devote to them is accurate

For example, if I'm (as I'm currently forced to due to understaffing) only able to see a veteran every 1-4 months for 'psychotherapy' 'sessions' (essentially, crisis management, suicide prevention, and mental health case management) and that veteran has primary diagnoses of severe clinical depression, severe PTSD, and alcohol use disorder (but won't see SUDS)...and, oh yeah, might have a touch of 'the ADHD,' then as I'm prioritizing how to spend my limited clinical face-time with him, I gotta say, I'm really DE-prioritizing chasing after the zebra of ADHD as a primary driver of dysfunction when we have established clinical depression, PTSD, and alcohol abuse as the major issues. I'm going to focus my time on trying to apply brief interventions (motivational interviewing, cognitive restructuring, relaxation training, problem-solving, behavioral activation) around THESE primary clinical issues and I'm quite unlikely to chase down the ADHD issue. Of course, every case is different, but in most cases there just isn't the 'treatment utility' payoff in doing so in these cases with so much psychiatric comorbidity staring me in the face and--as others have said--we want to focus on the treatable identified issues/diagnoses first and then perhaps 'treat' any residual issues potentially influenced by 'ADHD' later. Meanwhile, the veteran is pissed about not getting access to meds and complains to the patient advocate, administration, or even Congress. I'm not sure why a board certified psychiatrist making hundreds of thousands of dollars per year and who is--ostensibly--capable of and responsible for assessing/diagnosing and treating mental disorders can't independently assess/diagnose/treat ADHD with psychostimulant medication.

Entrenched historical hierarchies?

 

[erg923]

The idea that YOU have time for this stuff but they DON'T is devaluing of you/your profession and your time... AND of their profession too.

It is embarrassing that the mental health profession seems so flummoxed by such a routine clinical issue. I really don't know why we make this so damn difficult? It not easy, but we are trained to do not easy stuff...and its not like research on this disorder (both diagnosis and treatment) is lacking? I would take this fact to your leadership and be curious.

There are enough access challenges in the VA system that such a "spreading around" of diagnostic and treatment responsibility reflects poor organizational management and processes more than anything else, I would think?

 

[Fan_of_Meehl]

The idea that YOU have time for this stuff but they DON'T is devaluing of you/your profession and your time... AND of their profession too.

It is embarrassing that the mental health profession seems so flummoxed by such a routine clinical issue. I really don't know why we make this so damn difficult? It not easy, but we are trained to do not easy stuff...and its not like research on this disorder (both diagnosis and treatment) is lacking? I would take this fact to your leadership and be curious.

There are enough access challenges in the VA system that such a "spreading around" of diagnostic and treatment responsibility reflects poor organizational management and processes more than anything else, I would think?

Wish we had 'leadership.' We actually have dual-classed sycophants/tyrants. Sycophants to those above, tyrants to those below or, as I like to call it, masters of 'kissing ass upwards.'

 

[psych.meout]

Wish we had 'leadership.' We actually have dual-classed sycophants/tyrants. Sycophants to those above, tyrants to those below or, as I like to call it, masters of 'kissing ass upwards.'

 

[PsyDr]

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?

Either you are unaware or purposely ignoring the potential for malingering to get stimulants. Any idiot can read off the diagnostic criteria to adderall.

Putting reasonable barriers to that isn’t such a bad idea.

 

[erg923]

Either you are unaware or purposely ignoring the potential for malingering to get stimulants. Any idiot can read off the diagnostic criteria to adderall.

Putting reasonable barriers to that isn’t such a bad idea.

Adding a DKEFS or Trails or TOL isn't really a barrier. Peeps can easily skew those results/performance (unless you add a larger battery and add some SVT to the mix...but then we are back with the "too much" question). It's harder to feign a legitimate developmental and symptomatic history (all around) consistent with ADHD ...isn't it?

Well, I guess testing could be a "barrier" due to the deterrent factor (those tests suck).

 

[psych.meout]

Either you are unaware or purposely ignoring the potential for malingering to get stimulants. Any idiot can read off the diagnostic criteria to adderall.

Putting reasonable barriers to that isn’t such a bad idea.

Right, but people malinger to get benzos and opiates, too, and saying you've been having panic attacks or excruciating pain is probably easier than memorizing the DSM criteria. Is adding psychometric testing for the purposes of symptom or performance validity a good use of time and resources? Wouldn't a better method be comprehensive differential diagnosis and very limited prescriptions with judicious monitoring, if warranted?

 

[PsyDr]

Right, but people malinger to get benzos and opiates, too, and saying you've been having panic attacks or excruciating pain is probably easier than memorizing the DSM criteria. Is adding psychometric testing for the purposes of symptom or performance validity a good use of time and resources? Wouldn't a better method be comprehensive differential diagnosis and very limited prescriptions with judicious monitoring, if warranted?

IMO: It depends on how much skin you have in the game. If one is prescribing and risking the DEA knocking on their door; then he’ll yeah; Be as cautious as humanly possible. If one is providing behavioral therapy consistent with the MTA study, then maybe one is not risking as much.

(That’s a Faulkner level of BS grammar).

 

[psych.meout]

IMO: It depends on how much skin you have in the game. If one is prescribing and risking the DEA knocking on their door; then he’ll yeah; Be as cautious as humanly possible. If one is providing behavioral therapy consistent with the MTA study, then maybe one is not risking as much.

(That’s a Faulkner level of BS grammar).

What is the DEA going to do if you're following the proper standard of care and documenting accordingly, but your patient was savvy enough to trick you into prescribing them a conservative amount of a controlled substance?

 

[PsyDr]

What is the DEA going to do if you're following the proper standard of care and documenting accordingly, but your patient was savvy enough to trick you into prescribing them a conservative amount of a controlled substance?

You mean how are they going to come after prescribers who know that the mta study has shown limited efficacy of stimulants after a few months? And how did they do the exact same thing by changing the standards for the fda approved conditions for plates, and then turning around and blaming physicians who relied upon patient subjective report?

Because it gonna happen.

 

[cara susanna]

Not sure if this one has been posted yet or not but it seems like a decent review of issues in the assessment of ADHD in veterans/adults

That article was EXTREMELY helpful, thank you.

 

[clausewitz2]

You mean how are they going to come after prescribers who know that the mta study has shown limited efficacy of stimulants after a few months? And how did they do the exact same thing by changing the standards for the fda approved conditions for plates, and then turning around and blaming physicians who relied upon patient subjective report?

Because it gonna happen.

Honestly while there was an element of the DEA changing the criteria of what they considered reasonable and punishing prescribers who had not gotten with the times the people who got shut down or in criminal trouble either a) had very high volumes relatively or b) terrible documentation or c) got hit in a sting being fairly sloppy with decision-making.

At the same time plenty of psychiatrists these days refuse to prescribe benzos as well so stimulants are not the only legal therapeutic option they shy away from.

 

[AcronymAllergy]

What do you think about the idea that the prescribing provider (psychiatrist) might be in a position to decide who may be appropriate for prescription of the psychostimulant (via engaging in an actual differential diagnostic process themselves)? It just seems to me that attentional issues lie on a continuum and where--along that continuum of functioning--it is justified to give a formal diagnosis (of ADHD) and offer psychostimulant treatment and at what dose, and how long, and with what attendant adjustments, would be best determined by the prescribing provider in collaboration with the patient. That way the questions having to do with diagnostics, assessment (initial and ongoing), treatment (psychostimulant) response, and treatment (psychostimulant) adjustment could take place within the context of visits with the prescribing provider.

I realize that prescribers don't 'have a lot of time' to devote to these sorts of activities but: a) I'm not sure that's a valid reason that they shouldn't and b) I'm not sure that the commonly held assumption that therapists do have plenty of time to spare to devote to them is accurate

For example, if I'm (as I'm currently forced to due to understaffing) only able to see a veteran every 1-4 months for 'psychotherapy' 'sessions' (essentially, crisis management, suicide prevention, and mental health case management) and that veteran has primary diagnoses of severe clinical depression, severe PTSD, and alcohol use disorder (but won't see SUDS)...and, oh yeah, might have a touch of 'the ADHD,' then as I'm prioritizing how to spend my limited clinical face-time with him, I gotta say, I'm really DE-prioritizing chasing after the zebra of ADHD as a primary driver of dysfunction when we have established clinical depression, PTSD, and alcohol abuse as the major issues. I'm going to focus my time on trying to apply brief interventions (motivational interviewing, cognitive restructuring, relaxation training, problem-solving, behavioral activation) around THESE primary clinical issues and I'm quite unlikely to chase down the ADHD issue. Of course, every case is different, but in most cases there just isn't the 'treatment utility' payoff in doing so in these cases with so much psychiatric comorbidity staring me in the face and--as others have said--we want to focus on the treatable identified issues/diagnoses first and then perhaps 'treat' any residual issues potentially influenced by 'ADHD' later. Meanwhile, the veteran is pissed about not getting access to meds and complains to the patient advocate, administration, or even Congress. I'm not sure why a board certified psychiatrist making hundreds of thousands of dollars per year and who is--ostensibly--capable of and responsible for assessing/diagnosing and treating mental disorders can't independently assess/diagnose/treat ADHD with psychostimulant medication.

I'd say the psychiatrist is often in the best situation to make that determination, yep. Most of the time when the cases got to me, it was similar to some of the capacity cases I see--referring provider already had a good idea of what they thought, but wanted an outside opinion for support. It also used to be policy here to require the neuropsych. Fortunately, that's no longer the case.

It was fairly rare that I got ADHD cases for which the provider was genuinely stumped. I'll still sometimes handle those, depending on what's causing the stumped-ness.

 

[cara susanna]

Just wanted to ask: why is this such a pervasive problem? We are often referring people for ADHD testing in the community, they're seen by psychologists within reputable healthcare systems, and they all get a bunch of neuropsych tests. Now our providers are feeling worried that our testing won't be taken seriously, or that it's dumb for us to refer to the community when we could do more of this ourselves, so we should include more cognitive or performance testing. Are psychologists feeling pressured to give these tests? Is it so they can bill more? Is it that they just don't know?

 

[PikminOC]

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?

Yes DEA is coming down hard on controlled substance prescriptions so the diagnosis proven with testing is helpful. Theres alot of stimulants being sold by students....

 

[PikminOC]

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.

It's our way if making sure we have all the facts together before medicating for the wrong disorder

 

[PikminOC]

Just wanted to ask: why is this such a pervasive problem? We are often referring people for ADHD testing in the community, they're seen by psychologists within reputable healthcare systems, and they all get a bunch of neuropsych tests. Now our providers are feeling worried that our testing won't be taken seriously, or that it's dumb for us to refer to the community when we could do more of this ourselves, so we should include more cognitive or performance testing. Are psychologists feeling pressured to give these tests? Is it so they can bill more? Is it that they just don't know?

I have seen alot of very bad testing too so there's only one neuropsych I refer to.

 

[PikminOC]

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.

I thought it was very hard for vets to get stimulants as many of them come to my private practice seeking them. And that's why I read the testing and results. If they're not good I don't prescribe.

Lots of malingering for this diagnosis and treatment too. Testing can help separate that also.

 

[AcronymAllergy]

I thought it was very hard for vets to get stimulants as many of them come to my private practice seeking them. And that's why I read the testing and results. If they're not good I don't prescribe.

Lots of malingering for this diagnosis and treatment too. Testing can help separate that also.

It may be more difficult in VA than outside VA to get stimulants, but I still don't know that I'd call it "difficult" overall, at least based on my experiences across a few VAs. The psychiatrists there, much like you, just wanted to be reasonably confident in the diagnosis. For straightforward cases, they were typically comfortable assessing and treating on their own. For more complicated cases and/or situations where they suspected disingenuous presentations, they referred for testing, which was usually to me (the neuropsychologist). And that meant the patient would potentially have to wait 6-8 months to get in to an appointment with me, with which the psychiatrists were typically fine but the patients were often irked. So many of those patients would say they were going to try to find providers in the community (who didn't require all the testing).

But to be fair, as I don't typically go through a full neuropsych battery with most adult ADHD referrals, I would try to overbook these patients into 2- or 3-hour appointment slots to complete my interview and the limited testing I did perform (most or all of which was questionnaires). And sometimes all I needed was the initial interview (an hour or so) to give my impression to the referring psychiatrist. In the few cases where a full neuropsych was warranted, they'd usually have to wait, unfortunately.

 

[cara susanna]

Yes DEA is coming down hard on controlled substance prescriptions so the diagnosis proven with testing is helpful. Theres alot of stimulants being sold by students....

But, as the thread discusses, this testing isn't actually part of the diagnosis. Someone can do poorly on cognitive or performance tests, and that doesn't mean they have ADHD. Attention problems or deficits in cognitive functioning aren't even part of the diagnostic criteria.

 

[AcronymAllergy]

But, as the thread discusses, this testing isn't actually part of the diagnosis. Someone can do poorly on cognitive or performance tests, and that doesn't mean they have ADHD. Attention problems or deficits in cognitive functioning aren't even part of the diagnostic criteria.

But I imagine from DEA's perspective, it's "objective data." Or at the very least, it's evidence that the physician is consulting with other suitably-trained professionals to establish a diagnosis for which the treatment has substantial risk of diversion. Similarly to how pain physicians might refer a patient for a psychological evaluation before considering opioid medications...?

And particularly for PCPs, I doubt any of them have the time to sit down with a patient for an hour to perform an in-depth psychodiagnostic interview.

 

[PikminOC]

But I imagine from DEA's perspective, it's "objective data." Or at the very least, it's evidence that the physician is consulting with other suitably-trained professionals to establish a diagnosis for which the treatment has substantial risk of diversion. Similarly to how pain physicians might refer a patient for a psychological evaluation before considering opioid medications...?

And particularly for PCPs, I doubt any of them have the time to sit down with a patient for an hour to perform an in-depth psychodiagnostic interview.

And one hour isn't enough anyway. People come in with a litany of complaints.

 

[PikminOC]

But, as the thread discusses, this testing isn't actually part of the diagnosis. Someone can do poorly on cognitive or performance tests, and that doesn't mean they have ADHD. Attention problems or deficits in cognitive functioning aren't even part of the diagnostic criteria.

The testing is just one piece. The data helps us with the diagnosis but we ultimately make it.

 

[cara susanna]

But I imagine from DEA's perspective, it's "objective data." Or at the very least, it's evidence that the physician is consulting with other suitably-trained professionals to establish a diagnosis for which the treatment has substantial risk of diversion. Similarly to how pain physicians might refer a patient for a psychological evaluation before considering opioid medications...?

And particularly for PCPs, I doubt any of them have the time to sit down with a patient for an hour to perform an in-depth psychodiagnostic interview.

Our referrals mostly come from psychiatry, not primary care. I get why PCPs would refer, and those cases are usually much more straightforward. As I've mentioned before, we have this issue where no one in mental health will assess ADHD and will instead just refer for psych testing immediately.

I'm just frustrated by this perception that ADHD assessment requires cognitive testing, and that this perception seems to be shared by a lot of people within my own field. It feels like the psychologists in our clinic are the ones fighting an uphill battle by not including these tests.

 

[AcronymAllergy]

Our referrals mostly come from psychiatry, not primary care. I get why PCPs would refer, and those cases are usually much more straightforward. As I've mentioned before, we have this issue where no one in mental health will assess ADHD and will instead just refer for psych testing immediately.

I'm just frustrated by this perception that ADHD assessment requires cognitive testing, and that this perception seems to be shared by a lot of people within my own field. It feels like the psychologists in our clinic are the ones fighting an uphill battle by not including these tests.

I agree, I saw the same perception in some psychologists (and other providers) where I worked previously, and I was also frustrated by it. No independently-licensed mental health professional's knee-jerk reaction to every ADHD patient should be, "refer for neuropsych testing."

In our case, it would often be: PCP refers to PCMHI, then PCMHI auto-refers for testing. Our referrals from psychiatrists were much less frequent and frustrating. Whereas in my opinion, the process probably should've been: PCP refers to PCMHI, PCMHI then assesses and treats if possible before sending back to PCP. If PCMHI can't reasonably assess, refer to specialty mental health. The specialty MH provider then assesses and treats/recommends for treatment and either continues to follow in MH or sends back to PCP. If the specialty MH provider can't reasonably arrive at a diagnosis (or can tell by the consult from PCMHI that it's going to need a more thorough eval), then send for more testing.

 

[WisNeuro]

The testing is just one piece. The data helps us with the diagnosis but we ultimately make it.

The testing is irrelevant to the diagnosis. It is neither sensitive or specific, and there is no ADHD "profile". The only place that this is somewhat helpful is when designing specific accommodations for things like school or testing. In adults, possibly if there ADHD is bad enough to need work accommodations.

As for insurers, you need to check with their specific policies. Two of the big ones here will absolutely not pay neuropsych testing codes for ADHD diagnoses. And, their reimbursement for psych testing codes is very limited.

 

[neurotic_cow]

Our referrals mostly come from psychiatry, not primary care. I get why PCPs would refer, and those cases are usually much more straightforward. As I've mentioned before, we have this issue where no one in mental health will assess ADHD and will instead just refer for psych testing immediately.

I'm just frustrated by this perception that ADHD assessment requires cognitive testing, and that this perception seems to be shared by a lot of people within my own field. It feels like the psychologists in our clinic are the ones fighting an uphill battle by not including these tests.

We have this issue within our system as well. I'm in neuropsych and we get a ton of ADHD referrals from behavioral health, psychology, psychiatry, who could all reasonably make a diagnosis on their own most of the time. I'm not sure if they don't want to be the ones to tell the patients that they don't have ADHD in those cases or if its like you said where they assume that it requires cognitive testing? Either way, it's frustrating.

 

[PikminOC]

The testing is irrelevant to the diagnosis. It is neither sensitive or specific, and there is no ADHD "profile". The only place that this is somewhat helpful is when designing specific accommodations for things like school or testing. In adults, possibly if there ADHD is bad enough to need work accommodations.

As for insurers, you need to check with their specific policies. Two of the big ones here will absolutely not pay neuropsych testing codes for ADHD diagnoses. And, their reimbursement for psych testing codes is very limited.

I dont have the neuropsych just do adhd. I have them full testing. They have picked up autism and learning disorders and have been very helpful.

 

[PikminOC]

We have this issue within our system as well. I'm in neuropsych and we get a ton of ADHD referrals from behavioral health, psychology, psychiatry, who could all reasonably make a diagnosis on their own most of the time. I'm not sure if they don't want to be the ones to tell the patients that they don't have ADHD in those cases or if its like you said where they assume that it requires cognitive testing? Either way, it's frustrating.

If you dont want the business thats fine. Just let them know.

 

[WisNeuro]

I dont have the neuropsych just do adhd. I have them full testing. They have picked up autism and learning disorders and have been very helpful.

Autism, some insurers will reimburse for. They will not reimburse for LD in adults.

 

[borne_before]

I view testing for ADHD as a good way of identifying other issues (like internalizing concerns and SLDs) and as a way of helping to explain the why of ADHD and opportunity for psychoeducation and the need for stimulants. It can be very therapeutic.

 

[WisNeuro]

I view testing for ADHD as a good way of identifying other issues (like internalizing concerns and SLDs) and as a way of helping to explain the why of ADHD and opportunity for psychoeducation and the need for stimulants. It can be very therapeutic.

Definitely, good psych testing can be key here to correctly identifying what's going on from a psychiatric perspective. In most cases, though, cognitive testing is just a waste of resources, and often irresponsible from a provider point of view as the patient will be fronting some, if not all, of the cost for something they don't actually need to establish a diagnosis.

 

[PikminOC]

Definitely, good psych testing can be key here to correctly identifying what's going on from a psychiatric perspective. In most cases, though, cognitive testing is just a waste of resources, and often irresponsible from a provider point of view as the patient will be fronting some, if not all, of the cost for something they don't actually need to establish a diagnosis.

The patients in my practice who aren't drug seeking are glad to get the testing and find it helpful. Helps with treatment planning too

 

[borne_before]

The patients in my practice who aren't drug seeking are glad to get the testing and find it helpful. Helps with treatment planning too

Right! I mean it's really important to find out where people/kids with ADHD are academically and intellectually. You don't want anyone with an 80 IQ taking student loans thinking that now they're medicated, they can get a math phd.

 

[psych.meout]

I view testing for ADHD as a good way of identifying other issues (like internalizing concerns and SLDs) and as a way of helping to explain the why of ADHD and opportunity for psychoeducation and the need for stimulants. It can be very therapeutic.

Right! I mean it's really important to find out where people/kids with ADHD are academically and intellectually. You don't want anyone with an 80 IQ taking student loans thinking that now they're medicated, they can get a math phd.

Ok, but in that hypothetical situation, what's the incremental validity of a battery of neurocognitive testing over what you could garner from the thorough clinical interviewing and assessment you should be doing regardless of testing? Sure, you're not going to get a FSIQ without testing, but wouldn't you be able to do a diff. Dx of lower intellectual functioning vs ADHD without testing?

I'd bet testing could be justified for ADHD and other many cases, but there are limits to resources and providers who are competent in this kind of assessment.

The patients in my practice who aren't drug seeking are glad to get the testing and find it helpful. Helps with treatment planning too

This seems to be a similar situation to EMDR vs PE/CPT. The testing itself isn't really driving the effects as much as patients feeling that their evaluation and its results were more rigorous or sciencey because testing was done, not that there is necessarily significant incremental validity over an evaluation without testing.

 

[PikminOC]

Ok, but in that hypothetical situation, what's the incremental validity of a battery of neurocognitive testing over what you could garner from the thorough clinical interviewing and assessment you should be doing regardless of testing? Sure, you're not going to get a FSIQ without testing, but wouldn't you be able to do a diff. Dx of lower intellectual functioning vs ADHD without testing?

I'd bet testing could be justified for ADHD and other many cases, but there are limits to resources and providers who are competent in this kind of assessment.


This seems to be a similar situation to EMDR vs PE/CPT. The testing itself isn't really driving the effects as much as patients feeling that their evaluation and its results were more rigorous or sciencey because testing was done, not that there is necessarily significant incremental validity over an evaluation without testing.

To do a thorough psych eval like a scid for every complaint a patient has is not that easy to do in the current climate of managed care medicine. And as I posted above there is malingering to get these meds. Not that easy to quantify. We can agree to disagree.
I'm just pointing out what I see in my practice.
If people don't want to do the testing they can turn away the business.

 

[borne_before]

Ok, but in that hypothetical situation, what's the incremental validity of a battery of neurocognitive testing over what you could garner from the thorough clinical interviewing and assessment you should be doing regardless of testing? Sure, you're not going to get a FSIQ without testing, but wouldn't you be able to do a diff. Dx of lower intellectual functioning vs ADHD without testing?

I think there is a fundamental disconnect here. The goals of testing are the same as the goals of psychology: to explain/understand, predict, and influence behavior. Data is essential to reducing bias and the latter two goals of psychology. Of course you can often tell people who have lower IQs based on clinical interview, but what's to say the things we are "picking up on" aren't based on, in the worst cases, biases against an individuals class, race, or etc. For instance, a lot of educated/privileged/white people implicitly think that people who talk poor or have brown skin are of lower intelligence. But, when we have data, we are guarding against the worst of our instincts.

Now, how would you handle this: you have two parents, both physicians, in your office wanting you to test their 10-year-old son for ADHD. The kid is getting C's in his private school, displaying school refusal, outright academic rejection, is starting to withdraw. The kid is engaging in disruptive behaviors in class and is oppositional with parents during homework time. His parents have tried "everything" and he spends two hours in specialized tutoring after school - every day. He also stays in during recess to "catch" up.

In this scenario - you have two high IQ and high acheving parents. Their estimated IQ is probably around SS = 125. But guess what, kids tend to regress to the mean! After testing, their son's FSIQ is "only" 110. Achievement testing shows that the kid is functioning about 18 months ahead of schedule. In this instance, the psychologist should have a conversation about setting appropriate learning expectations with parents before this kid gets suicidal or ends up burnt out.

People do not do pursue an ADHD diagnosis to simply find out whether or not they have ADHD. The ADHD diagnosis is often secondary to other issues and questions like "why isn't my life going the way I want it to?"- ADHD can explain some of that for people with ADHD, the treating of ADHD is secondary to the individual's goals and data helps us to understand, set appropriate expectations, and therefore help the individual thrive. The treatment for ADHD is different than it is for someone with dyslexia and borderline IQ. You cannot interview for dyslexia - even so, you need data to guide the appropriate treatments (is it dyphonetic dyslexia or dysfluent or is this orthographic).

Without testing/data, that is just, like, your opinion, man. The data is essential for greater things than just "does the kid have ADHD." That being said, you do have simple ADHD cases in some people and it has a clear neurodevelopmental documentation/trajectory. In those cases testing is likely superfluous. I also do think stimulants are probably over prescribed and there is too much church marming about drug seeking behaviors form prescribers (because of the real risk of getting sued).

 

[psych.meout]

To do a thorough psych eval like a scid for every complaint a patient has is not that easy to do in the current climate of managed care medicine. And as I posted above there is malingering to get these meds. Not that easy to quantify. We can agree to disagree.
I'm just pointing out what I see in my practice.

But if thorough psych eval isn't possible, then how is testing, which is on top of that, possible, even for just cases of suspected ADHD?

If people don't want to do the testing they can turn away the business.

It's not simply about "turning away business," it's also about considering the patient. As @WisNeuro pointed out, often times patients themselves or their families are footing the bills for these out of pocket, either entirely or awaiting reimbursement from their insurance, if it ever comes. Thus, it's important whether you can answer the question(s) at hand with something that is significantly less expensive for them. It's a not insignificant ethical issue if you're steering someone into testing because it's satisfying your concerns/curiosity or adding to your bottom line without considering what footing the bill for it is going to do to them.

I think there is a fundamental disconnect here. The goals of testing are the same as the goals of psychology: to explain/understand, predict, and influence behavior. Data is essential to reducing bias and the latter two goals of psychology. Of course you can often tell people who have lower IQs based on clinical interview, but what's to say the things we are "picking up" aren't based on, in the worst cases, biases against an individuals class, race, or etc. For instance, a lot of educated/privileged/white people implicitly think that people who talk poor or have brown skin are of lower intelligence. But, when we have data, we are guarding against the worst of our instincts.

Are we? Many different kinds of providers, from physicians to psychologists to nurses to social workers, have plenty of hard data, but they still end up treating patients disparately depending on demographic factors like race, ethnicity, LGBTQ+ status, etc. And this doesn't even get into other misuses of data that lead to even more consequential disparities in the legal system (e.g., death row inmates with possible ID).

I'd posit that other considerations and practices (e.g., cultural and linguistic competency, being up to date on the literature in disparities, SES and race, etc.) are what guard against these issues, not simply having data from neurocognitive testing. Sure, having data can help, but not absent the other sociocultural competencies that are what's really driving resolution of disparities in these cases.

Now, how would you handle this: you have two parents, both physicians, in your office wanting you to test their 10-year-old son for ADHD. The kid is getting C's in his private school, displaying school refusal, outright academic rejection, is starting to withdraw. The kid is engaging in disruptive behaviors in class and is oppositional with parents during homework time. His parents have tried "everything" and he spends two hours in specialized tutoring after school - every day. He also stays in during recess to "catch" up.

In this scenario - you have two high IQ and high acheving parents. Their estimated IQ is probably around SS = 125. But guess what, kids tend to regress to the mean! After testing, their son's FSIQ is "only" 110. Achievement testing shows that the kid is functioning about 18 months ahead of schedule. In this instance, the psychologist should have a conversation about setting appropriate learning expectations with parents before this kid gets suicidal or ends up burnt out.

I mean, it sounds like the parents already have lots of data and what's going on with the kid is a lot more about them than him. They could very easily dismiss the test results with any number of rationalizations. I've seen it quite a bit on the cases I worked on and every supervisor had a wealth of experience of this as well.

People do not do pursue an ADHD diagnosis to simply find out whether or not they have ADHD. The ADHD diagnosis is often secondary to other issues and questions like "why isn't my life going the way I want it to?"- ADHD can explain some of that for people with ADHD, the treating of ADHD is secondary to the individual's goals and data helps us to understand, set appropriate expectations, and help the individual thrive. The treatment for ADHD is different than it is for someone with dyslexia and borderline IQ. You cannot interview for dyslexia - even so, you need data to guide the appropriate treatments (is it dyphonetic dyslexia or dysfluent or is this orthographic).

Aren't you kind of undercutting your argument in favor of this broad application of testing by pointing at that the real questions are independent of testing and which are ones that need to be addressed by other skills in our training (e.g., therapy)?

Without testing/data, that is just, like, your opinion, man. The data is essential for greater things than just "does the kid have ADHD." That being said, you do have simple ADHD in some people and it has a clear neurodevelopmental documentation/trajectory. I also do think stimulants are probably over prescribed and there is too much church marming about drug seeking behaviors.

Ok, but by that token, why not do testing for virtually every presenting issue? There are demonstrable neurocognitive deficits for variety of maladies, including psychopathology, chronic pain, cancer, etc. Should we do testing for all of those cases?

And people also have a variety of broader concern beyond actual diagnosable problems, so why not do testing for even subclinical complaints, like occupational dissatisfaction and malaise? Wouldn't it be helpful to figure out if they're having more objective cognitive impairment or whether it's more likely burnout, dissatisfaction, concerns about being passed over for their age, etc?

 

[PikminOC]

But if thorough psych eval isn't possible, then how is testing, which is on top of that, possible, even for just cases of suspected ADHD?

It's not simply about "turning away business," it's also about considering the patient. As @WisNeuro pointed out, often times patients themselves or their families are footing the bills for these out of pocket, either entirely or awaiting reimbursement from their insurance, if it ever comes. Thus, it's important whether you can answer the question(s) at hand with something that is significantly less expensive for them. It's a not insignificant ethical issue if you're steering someone into testing because it's satisfying your concerns/curiosity or adding to your bottom line without considering what footing the bill for it is going to do to them.


Are we? Many different kinds of providers, from physicians to psychologists to nurses to social workers, have plenty of hard data, but they still end up treating patients disparately depending on demographic factors like race, ethnicity, LGBTQ+ status, etc. And this doesn't even get into other misuses of data that lead to even more consequential disparities in the legal system (e.g., death row inmates with possible ID).

I'd posit that other considerations and practices (e.g., cultural and linguistic competency, being up to date on the literature in disparities, SES and race, etc.) are what guard against these issues, not simply having data from neurocognitive testing. Sure, having data can help, but not absent the other sociocultural competencies that are what's really driving resolution of disparities in these cases.


I mean, it sounds like the parents already have lots of data and what's going on with the kid is a lot more about them than him. They could very easily dismiss the test results with any number of rationalizations. I've seen it quite a bit on the cases I worked on and every supervisor had a wealth of experience of this as well.


Aren't you kind of undercutting your argument in favor of this broad application of testing by pointing at that the real questions are independent of testing and which are ones that need to be addressed by other skills in our training (e.g., therapy)?


Ok, but by that token, why not do testing for virtually every presenting issue? There are demonstrable neurocognitive deficits for variety of maladies, including psychopathology, chronic pain, cancer, etc. Should we do testing for all of those cases?

And people also have a variety of broader concern beyond actual diagnosable problems, so why not do testing for even subclinical complaints, like occupational dissatisfaction and malaise? Wouldn't it be helpful to figure out if they're having more objective cognitive impairment or whether it's more likely burnout, dissatisfaction, concerns about being passed over for their age, etc?

If they don't like my recommendations they can find a new doctor. Lots of docs out there will prescribe Adderall at the first appt.

 

[AcronymAllergy]

Some of the disconnect between approaches could perhaps be addressed via informed consent with the patient and discussion with referral sources. For example, when meeting with the patient initially (or when scheduling the initial appointment), review the options. You can evaluate for the primary purpose of diagnostic clarification, which may not entail much beyond an in-depth interview and perhaps some questionnaires, and which should still allow you to provide a good bit of information to the patient and the referral source. Or you can do that plus additional cognitive testing, which you anticipate will cost $X and will likely will not be covered by insurance, as it is not necessary to arrive at a diagnosis (assuming this is true), but that will provide additional information that may (or may not) be of use to the patient and referral source.

 

[WisNeuro]

I'd be fine with it if the referring doc was very upfront about testing in the informed consent, though I doubt any are.

"I'm going to require neuropsychological testing before I prescribe you anything. Now, the testing adds absolutely nothing to the actual diagnosis, and you're probably going to have to pay out of pocket, but them's the shakes. But, if you really want to know what your IQ is, hey, that's kind of cool. Sort of. Hey, welcome to medicine in the US, ain't it neat!"

But, no one is really doing that. They're telling the patient that this is what they need for X to happen. They aren't told alternatives, they aren't informed that some of the hoops are irrelevant and only serve the needs of the referring prescriber and not the patient. Simply, this is just an example of bad medicine. I'm all for driving business to my colleagues, but not at the price of exploiting vulnerable patients.

 

[psych.meout]

If they don't like my recommendations they can find a new doctor. Lots of docs out there will prescribe Adderall at the first appt.

That's not really addressing the point I was making and with which you tacitly agreed (e.g., "To do a thorough psych eval like a scid for every complaint a patient has is not that easy to do in the current climate of managed care medicine"), which is that there are logistical and financial concerns to get testing for even just patients with suspected ADHD, especially when testing is not required or part of the standard of care to diagnose it.

 

[erg923]

To do a thorough psych eval like a scid for every complaint a patient has is not that easy to do in the current climate of managed care medicine.

But you think having someone else doing an 8 hour eval at thrice the cost IS a more feasible and fiscally responsible practice in the reality of managed care? This makes no sense.

There are structured interviews for suspected ADHD.

 

[cara susanna]

I'd be fine with it if the referring doc was very upfront about testing in the informed consent, though I doubt any are.

"I'm going to require neuropsychological testing before I prescribe you anything. Now, the testing adds absolutely nothing to the actual diagnosis, and you're probably going to have to pay out of pocket, but them's the shakes. But, if you really want to know what your IQ is, hey, that's kind of cool. Sort of. Hey, welcome to medicine in the US, ain't it neat!"

But, no one is really doing that. They're telling the patient that this is what they need for X to happen. They aren't told alternatives, they aren't informed that some of the hoops are irrelevant and only serve the needs of the referring prescriber and not the patient. Simply, this is just an example of bad medicine. I'm all for driving business to my colleagues, but not at the price of exploiting vulnerable patients.

EXACTLY. In our clinic, and apparently many others, the neuropsych testing is a hoop the patient has to jump through before they can get the diagnosis and, consequently, meds. And I get the impression it's because doctors are reluctant to prescribe stimulants without the patient having to demonstrate some effort. Which is fine, I totally get that, but to me "should this patient get meds?" is a separate issue from "does the patient have this diagnosis?" We even have psychiatrists who will make the patient do testing here after they've already been diagnosed by another provider, even in the same system, if that diagnosis wasn't obtained through psych testing.

This is further complicated by two things: 1) our neuropsych dept is over a 90 min drive away and 2) neuropsych testing in the community is really, really backlogged. To make a patient drive or wait for neuropsych testing when evidence suggests it's not necessary, to me is NOT patient-centered care.

If they don't like my recommendations they can find a new doctor. Lots of docs out there will prescribe Adderall at the first appt.

Not in VA mental health. We've had patients who've been on stimulants for years in the community who then lose their insurance, come into our system, and are told they need psych testing before they can get meds from us. Even if they were diagnosed or did testing as a kid, they have to redo it unless they can get a copy of the previous testing. And, at least here, Primary Care refuses to prescribe them. Then they see me, I diagnose ADHD (wow, go figure) and then they get meds. The thing is, my psychologist colleagues and I are not necessary for this. Any licensed mental health provider could do what we are doing for our current ADHD assessment practice, minus the MMPI-2 or PAI that we include for a validity check. It's only delaying the patient's care.

 

[calimich]

Thankfully Pearson is ahead of all this.

 

[Sanman]

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?

Cool, so they are punting the responsibility to you guys because they can't be bothered.

Honestly, IME, most of the Adult ADHD testing is garbage because unlike with school and home, you rarely get the chance to evaluate performance in two or more settings. Add to that the lack of sleep that is pervasive among adults and likely the cause of the majority of complaints in these cases and you cannot get an accurate dx. Gruber et al (2007) and Dan et al (2020) have shown that sleep deprivation affects performance on the CPT and other tasks in both children and young adults. So, the results in most cases would not improve the differential of ADHD vs sleep deprivation. So, the answer really should be that there is inadequate info to dx in most cases.