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?
