Thanks for posting your overview -- I really liked reading how you walk through this diagnosis with patients and their families.
I do worry about that! But, I often only emphasize this when a parent is likely to dismiss the diagnosis or not pursue medical treatment. I also emphasize the born with it part to get parents understanding that it does impact life course. It's not just "boys being boys."
The VA patients then go to private Psychiatrists for disability and other evals. It's not a matter of difficulty saying so, I want the correct diagnoses to assist the patient.
Untrue. There are many other things the DEA is looking for like the drug screens and pill counts. I haven't see physicians get in trouble for not having the testing.
Inverting this doesn't change the point. The point is that the blame for the overprescribing is excused by the diagnosis that was made by the Psychologist, and then the blame is shifted to the Psychologist. It is not as if everyone is going to get exonerated when the DEA comes around - someone will be blamed.
Yes, because VA patients have so much money to go to private Psychiatrists...
Not all of them. But when they can't get what they want they doctor shop too. Ive had a few in my practice
When I have seen physicians get in trouble with the DEA it's because the patients are having insufficient tox screens or failed ones. Or the physician is over prescribing like 90 days worth of meds in 30 days. The psychologist report isn't going to save them in those cases.
Yes, of course, that is what they do when they can't get their Ritalin or whatever any other way. However, if they can get if from a VA Psychiatrist, they obviously will.
Well yes, if someone messes up that badly and obviously, of course they will get in trouble. That is not the point at all.
Their cases are complex to me. The come in for disability evals too. I refer those cases for neuropsych testing also.
It really is the point. The dea doesn't come sniffing unless something hinky is going on. And then the onus is on the physician to defend the prescription habit. So far, I haven't seen any cases where having psych testing helps in a dea case as that's not what's being looked at.
I get why a practitioner would want to shield from liability. It also can be a good way to practice to have more thorough assessment. In my experience the referrals for ADHD evals came more from primary care and was typically to rule out other diagnoses. As far as shifting blame when the DEA comes around…huh? Are you saying the DEA would go after the psychologist for diagnosing ADHD?
I am not sure the DEA would do that or even could - anything seems possible. I think it would be more harmful to the Psychologist with the hospital or clinic administrators, or perhaps just very unnerving with no real harm done. Hard to predict.
"Hinky" covers a wide variety of things. You may not have seen any cases where psych testing helped, but maybe it does and you don't know, or maybe it has no effect at all. The truth is it's an unknown to you; I doubt that you've seen enough of this to have anything like a representative sample.
The concern I have is perhaps more subtle and more tied to ongoing treatment and treatment adjustment (e.g., dosing modifications, decisions to continue vs. discontinue the stimulant due to weighing adverse effects vs. benefits, etc.). Since attentional dysfunction lies on a continuum and since the use of stimulant medication to target this symptom is the goal of the treatment, then I think these decisions should emerge from the initial and continuing interactions between the prescribing provider and patient. By saying, essentially, 'well...we will send you to a psychologist who will then render a yes/no decision on whether you 'have' this 'disease' (after a one-time meeting with you) and then dichotomize our treatment plan into 'if you have it you get meds, if you don't then you don't get meds'--I think that this is a suboptimal approach. There also, as far as I can tell, no magic testing battery or results that reliably sort people into the 'have ADHD' vs. 'don't have ADHD' camps. So, from what I can tell in listening to people who know this literature and practice best...you're basically doing in depth interview, observation, and differential diagnosis which--I would argue--may be best done as a longitudinal enterprise over the course of knowing, interacting with, and treating the patient (and observing results). I mean, I get that prescribing providers wouldn't necessarily have 'the time' to do the in depth interviewing and would need to farm that out to non-prescribers---that's cool and makes sense. I just am not a big fan of the patient saying 'I have ADHD and need meds' being sent to a psychologist to essentially 'give permission' for them to receive the meds with the perception that they're going to employ some sort of specific assessment-related sorcery to 'make the diagnosis' after a single encounter. The other thing I'd say is that I've almost never seen (I can't remember seeing) the answer being 'no...this patient does not have ADHD'...if it happens, it rarely happens. Which has the practical upshot of rendering the entire process ceremonial and a complete waste of time and resources.
I have been getting referrals for ADHD evaluations recently from a local NP. Seems like an unnecessary hoop to me. I also see so many people diagnosed with ADHD and being prescribed stimulants for whom it is probably not an accurate diagnosis but they are committed to the idea and the medication is reinforcing so they are not going to want to change it. I recently have heard two separate stories of distracted driving being blamed on ADHD and both “needed” an increase in their vyvanse and both are showing signs of stimulant use that I recognize from my days working with a lot of meth users. My experience is that the person who really has ADHD (whatever that really is) and experiences a longer term benefit from stimulants is pretty rare. Because of this I tend to be very pessimistic when I have a patient who is on stimulants and I am optimistic about much more severe cases typically.
I follow a great deal of disciplinary actions and am a referral source for my local Medical Board in these kinds of cases.
I don't think people should gets meds all the time. Lots of other interventions out there. And psych testing isn't magic. It's just another piece of the puzzle.
I prescribe very few controlled subs
I continue to contend that despite this I still doubt that you've seen enough of this to have anything like a representative sample.
They are trying to avoid complaints to the medical board or the entity they work for or both.
I think that might be exactly why it is done - a certain percentage of patients will forego the whole thing altogether and get their stimulants elsewhere.
Then please show me your proof where psychologists have been pointed to as the entity in the wrong during a dea investigation.
I don't think that is anything that would be done publicly if at all - it is simply to redirect heat off the prescriber, not to necessarily direct it onto the Psychologist which I doubt DEA could actually do.
Not sure why you are being so rigid about this. The physician is where the buck stops. @lobelsteve
If that were true Psychiatrists would not order Neuropsych testing for suspected ADHD
It's to help the patient optimally. It's still a piece for treatment. Not a dea issue.
It looks like your avatar might have been using them all. Is that from southpark and the world of Warcraft episode? That is one of my favorites. I almost dropped out of undergrad because of an online mmorpg. I didn’t leave the house other than to go to class for like three months and barely slept at all.
Testing and treatment are different.
The part where Cartman's mom helps him with defecating so his play is uninterrupted is the best example of a parent so afraid of their kid and letting their kid have big emotions that i've ever seen.
I ask to get clarification on all the diagnoses a person is suffering from. Many treatment referrals to exec function and coaching and school accommodations if indicated.
In my mind, ADHD testing, whatever that is, is less important than cognitive testing for kids who are struggling in school. That might be what heist is thinking about. Also, I think of ADHD as a disorder of exclusion. That is to say, attentional problems are characteristic of many if not most diagnoses and if the problem is better accounted for by that, then that is what is treated. Unfortunately, that’s not what I see typically and the real problems get worse while the person is “treated“ for “my ADHD” and then they get more diagnoses added and more medications. In my experience, that is sort of common practice.
The testing psychologist facebook group often has these discussions. Usually the question is "What's a good test for ADHD?" Beside naming things like CPT, DKEFS, etc., no one ever really discusses the importance of establishing a developmental history of hyperactive/impulsive behaviors. It is a neurodevelopmental disorder after all. Drives me bonkers, man.
Actually, Barkley points out that EF testing actually often DOESN'T show differences, with false negatives rates between ~35-80+ percent.
ADHD testing cannot be helpful for treatment, in that there is no such thing as empirically validated ADHD testing. It's like asking how helpful unicorns are for riding to work. I know that @cara susanna knows this and was asking this in a challenging way, but, logically, don't you need to actually define "EFT/Neuropsych testing for ADHD" before you can evaluate whether or not it's effective? Can any of you on the "ADHD testing can't hurt" side of the argument please define the term "ADHD testing"?
I'll admit it was an oversimplification (and EF is also a huge, somewhat amorphous cognitive domain). There are studies in which some cognitive tests show group-level differences between some individuals with ADHD and healthy controls. The trouble, like you've referenced, is that the differences are not always particularly large, are not always consistent across studies, and there are a not-insubstantial number of individuals diagnosed with ADHD who perform WNL on testing, resulting in...limited diagnostic utility.
Barkely does reference these group differences findings, but (rightfully so, IMHO) points out that such findings are of little to no use at the individual diagnostic level.
