PhD/PsyD "On and off testing" for kids ADHD or suspected ADHD

[erg923]

Does this hold any water? I don't get it. I have never even seen literature on this in terms of diagnostic discrimination and/or how it actually meaningfully informs/contributes to treatment or treatment plan changes. If this was so impactful and important, I would have thunk I would have learned about it or had to read at least one article about it in my grad school assessment/diagnosis and childhood-disorder treatment classes. Yet, I did not.

Let' see, you give child a stimulant and test them twice with a CPT or something similar. They then do worse off a stimulant. So what, so would most people, right? How is that useful?

Conversely... no change. What do you do with clinically? How would that change a treatment plan? Its not like a CPT has much ecologically validity. Why the hell do so many psychologists want to do this?

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[Justanothergrad]

It would probably help if the CPT had good descriminste capability to start with, but no- given that testing data sucks for ADHD diagnosis I'm not sure why the pre/post testing makes sense or offers anything.

 

[psych.meout]

Why the hell do so many psychologists want to do this?

$?

 

[WisNeuro]

There is something to having a kid off meds when testing if you are also looking at possible LD or other neurodevelopmental issues. You need to get a good picture of their actual baseline. As for the on and off testing, it's just BS. Good way to keep your clinic full with multiple re-tests for no good reason.

 

[Ollie123]

Great research design for behavioral pharmacology studies trying to understand medication effects and disorder etiology.

Completely unnecessary in clinical practice.

That said, this is probably a great way to convince schools to provide accommodations to folks who otherwise wouldn't qualify ("See? He did better on stimulants!"). Plenty of unscrupulous providers out there who would readily do this to make the parents happy.

 

[PsyDr]

Great research design for behavioral pharmacology studies trying to understand medication effects and disorder etiology.

Completely unnecessary in clinical practice.

That said, this is probably a great way to convince schools to provide accommodations to folks who otherwise wouldn't qualify ("See? He did better on stimulants!"). Plenty of unscrupulous providers out there who would readily do this to make the parents happy.

1) I don't see why any of us would talk trash about a reasonable activity that also produces money. There's things to disagree about, but it is not that out there. It's like running an EKG on a kid before prescribing stimulants. Probably a good idea, but the research doesn't show a difference between sudden death in stimulants vs. controls.

2) If the formal testing groups like SAT, ACT, LSAT, etc can require administration of both the timed and untimed versions of that one test (OGRT IIRC?); I see no problems with something similar in ADHD.

 

[Ollie123]

Concerns emerge when something: A) Isn't standard practice; and B) Biases results in favor of obtaining the result a patient is seeking. Why do testing at all vs just have them buy a stock report and copy/paste in the name? Though admittedly, I don't think the results are not 100% clear that MPH enhances cognitive performance in healthy controls - seems to depend on the test and a bajillion other factors. If an appropriate justification is in place for doing both I think it is a perfectly reasonable decision. There certainly could be situations where it is reasonable to do this for one reason or another. However, given it isn't necessary to make the diagnosis (and can potentially be misleading) I would seriously question this being done routinely for anyone who walks through the door. EKGs are done for safety assessment and not to confirm diagnosis. Completely different situation.

Nothing at all wrong with making money while acting in line with standards of care. However, there are certainly providers out there who clearly work to "Get the child accommodations" rather than test. There are others who routinely push the bounds towards things that generate profit for them. Where that line gets drawn can be fuzzy, but it needs to be there.

 

[PsyDr]

Concerns emerge when something: A) Isn't standard practice; and B) Biases results in favor of obtaining the result a patient is seeking. Why do testing at all vs just have them buy a stock report and copy/paste in the name? Though admittedly, I don't think the results are not 100% clear that MPH enhances cognitive performance in healthy controls - seems to depend on the test and a bajillion other factors. If an appropriate justification is in place for doing both I think it is a perfectly reasonable decision. There certainly could be situations where it is reasonable to do this for one reason or another. However, given it isn't necessary to make the diagnosis (and can potentially be misleading) I would seriously question this being done routinely for anyone who walks through the door. EKGs are done for safety assessment and not to confirm diagnosis. Completely different situation.

Nothing at all wrong with making money while acting in line with standards of care. However, there are certainly providers out there who clearly work to "Get the child accommodations" rather than test. There are others who routinely push the bounds towards things that generate profit for them. Where that line gets drawn can be fuzzy, but it needs to be there.

We probably have different patient experiences.

1) I agree that there are psychologists who are practicing outside the community standard of care.
2) Even outside the standards of care, it is fine to practice in a way that is considered prudent by a reasonable minority.
3) If we believe that we should 100% run by the empirical base, then EKGs should NOT be performed in pediatric stimulant patients because the research, like the cognitive assessment in ADHD research, does not show that this is supported.
4) My real point is: If there is a disorder that requires a cognitive impairment to meet diagnostic criteria, the only way to determine if there is an impairment is to measure said cognitive ability. If treatment is meant to improve said cognitive ability, one should measure such a response. If the disorder isn't actually due to cognitive impairment, then the entire construct is neither valid nor reliable.

 

[Justanothergrad]

We probably have different patient experiences.
4) My real point is: If there is a disorder that requires a cognitive impairment to meet diagnostic criteria, the only way to determine if there is an impairment is to measure said cognitive ability. If treatment is meant to improve said cognitive ability, one should measure such a response. If the disorder isn't actually due to cognitive impairment, then the entire construct is neither valid nor reliable.

I don't disagree with you about this criteria being a solid potential and great idea- the issue becomes if the cognitive tests being utilize are effective discriminant for the disorder. If they aren't, then using that method isn't any more valid or reliable than if the criteria is not accurate or reliable itself. I've not seen literature supporting a strong discriminant capacity of any cognitive test for identifying ADHD with good PPV/NPV.

 

[WisNeuro]

I don't disagree with you about this criteria being a solid potential and great idea- the issue becomes if the cognitive tests being utilize are effective discriminant for the disorder. If they aren't, then using that method isn't any more valid or reliable than if the criteria is not accurate or reliable itself. I've not seen literature supporting a strong discriminant capacity of any cognitive test for identifying ADHD with good PPV/NPV.

It's not that there is no single test, it's that there is also no cognitive pattern of ADHD. With some neuropathology, the time course and pattern of cognitive testing can be solid diagnostically, even if any one test is not.

 

[PsyDr]

I don't disagree with you about this criteria being a solid potential and great idea- the issue becomes if the cognitive tests being utilize are effective discriminant for the disorder. If they aren't, then using that method isn't any more valid or reliable than if the criteria is not accurate or reliable itself. I've not seen literature supporting a strong discriminant capacity of any cognitive test for identifying ADHD with good PPV/NPV.

If a blood pressure monitoring/sphygmomanometry did not discriminate between hypotension/hypertension/isotension would you consider the diagnostic entity valid?

If the tests are not discriminant, then the construct isn't valid.

 

[Justanothergrad]

If a blood pressure monitoring/sphygmomanometry did not discriminate between hypotension/hypertension/isotension would you consider the diagnostic entity valid?

If the tests are not discriminant, then the construct isn't valid.

Why would you assume that measurement error can't be the problem? It's possible to measure something badly and yet the thing still exist.

It's not that there is no single test, it's that there is also no cognitive pattern of ADHD. With some neuropathology, the time course and pattern of cognitive testing can be solid diagnostically, even if any one test is not.

Are you saying that over time, there is an explicit pattern of cognitive domain testing that is indicative of ADHD? I've not seen evidence to support course/pattern of testing as diagnostic of ADHD. Perhaps I'm not understanding what you mean though.

 

[WisNeuro]

Are you saying that over time, there is an explicit pattern of cognitive domain testing that is indicative of ADHD? I've not seen evidence to support course/pattern of testing as diagnostic of ADHD. Perhaps I'm not understanding what you mean though.

Not at all. I was generally agreeing with you, but just adding nuance. For many neuropathological disorders, there is no one test with great sens/spec for diagnostic purposes. But, with some, certain cognitive patterns (e.g., amnestic pattern with semantic retrieval deficits in AD, etc) can be very accurate at diagnosis. ADHD has neither going for it.

 

[PsyDr]

Why would you assume that measurement error can't be the problem? It's possible to measure something badly and yet the thing still exist....

For the same reason I don't assume that psychiatric illness is caused by ghosts that invade someone's mind.

 

[Justanothergrad]

For the same reason I don't assume that psychiatric illness is caused by ghosts that invade someone's mind.

Sort of an odd analogy. There are decades worth of research showing poor measurement capacity with regards to specificity of intellectual and neuro-psych problems. That's what you get when you have a young field. It seems like a waste to throw the baby (in this case, that attention processing has neurological underpinnings that may be able to be assessed with testing in the future, if testing were improved) out with the bathwater of documented poor classification accuracy for many current testing approaches. As it stands, the testing approaches for ADHD don't work. That doesn't mean ADHD could not be measured by better tests or that they should be ruled out in the future as those approaches evolve.

 

[erg923]

I think my original point may have gotten lost or wasn't well stated.

We do this, and then what do we do with it that actually changes treatment...and changes treatment for the betterment of the patient?

This isn't academics. Test people to death to learn about about the disorder in studies/trials, but if you are doing something in your clinical practice and it doesn't result in information that is actually used to inform/change the treatment, then its a waste of time and money. I think we all agree that this isn't diagnostic in any way, which I suspect is the actual view/rationale from these practitioners... sadly.

I think the aforementioned practice perpetuates gross misunderstandings about ADHD within our field. Its pretty shocking how many practitioners cling to beliefs that have no empirical basis because they find it "useful." Although they never seem to be able to actually operationalize the "useful" part in terms of treatment differences. If your assessment measures don't translate into this, then its just masturbation.... or trying to bill another hour of testing.

 

[PsyDr]

Sort of an odd analogy. There are decades worth of research showing poor measurement capacity with regards to specificity of intellectual and neuro-psych problems. That's what you get when you have a young field. It seems like a waste to throw the baby (in this case, that attention processing has neurological underpinnings that may be able to be assessed with testing in the future, if testing were improved) out with the bathwater of documented poor classification accuracy for many current testing approaches. As it stands, the testing approaches for ADHD don't work. That doesn't mean ADHD could not be measured by better tests or that they should be ruled out in the future as those approaches evolve.

You're missing my point.

If the disorder is an impairment in attention, the we have to measure it. If measurement of attention does not show differences, the construct is wrong.

There are clear neurological underpinning of ADHD that are shown in cortical maturation studies. This does not mean this is an attention disorder.

 

[erg923]

My understanding is that the name is misleading and does not capture what is going on with this heterogeneous disorder...or at least its heterogeneous clinical presentation in children and adolescents?

A developmental disorder of executive functioning can lead to attention problems is some circumstances but not others. But treating it like an inability to pay attention and thus would be able to be captured and diagnosed by laboratory tests like the CPT seems like a gross misunderstanding of how this disorder works and presents, no?

By the way, much like insomnia and "Doc, I cant sleep?" this is not a real interest/passion of mine. It is NOT why I got into this field, and it would be quite boring to me if it weren't so controversial in terms of how we assess it and understand it. However, it's an area that is responsible for a disproportionate amount of psych resource utilization in this country (now my business/area of work), and I am surprised out how poorly understood and misunderstood it is by the practitioners that are suppose to be the experts on this stuff (psychologist and psychiatrists).

 

[Therapist4Chnge]

For the same reason I don't assume that psychiatric illness is caused by ghosts that invade someone's mind.

Maybe we should consult the Internet/social media....

Okay...maybe not.

 

[erg923]

Maybe we should consult the Internet/social media....
View attachment 241847

Okay...maybe not.

I would have liked to grown up in the 30s and 40s. Although much like my grandfather, I would only do it if I knew I would survive my WWII service.

Psych was new and (dumb) exciting then. I don't think we had ADHD then either. The Nuns and Priests at school were also very mean, from what I understand from my parents and grandparents anyway. Ah, the olden days....

 

[PsyDr]

@Therapist4Chnge

That’s almost a play by play for how that psychologist treated The Beach Boys.

 

[Pragma]

 

[singasongofjoy]

2) If the formal testing groups like SAT, ACT, LSAT, etc can require administration of both the timed and untimed versions of that one test (OGRT IIRC?); I see no problems with something similar in ADHD.

What do you mean? Folks who get accommodation of extra time / untimed version also have to take a timed version?

 

[singasongofjoy]

However, it's an area that is responsible for a disproportionate amount of psych resource utilization in this country (now my business/area of work), and I am surprised out how poorly understood and misunderstood it is by the practitioners that are suppose to be the experts on this stuff (psychologist and psychiatrists).

I'm intrigued. Can you share a bit more about what it is you're doing these days?

 

[PsyDr]

What do you mean? Folks who get accommodation of extra time / untimed version also have to take a timed version?

For reading disorders, patients seeking accommodations such as extra time, on the LSAT, have to have extremely specific tests that have a both a timed and untimed condition. Iirc, the testing company only accepts one test.

 

[PikminOC]

My understanding is that the name is misleading and does not capture what is going on with this heterogeneous disorder...or at least its heterogeneous clinical presentation in children and adolescents?

A developmental disorder of executive functioning can lead to attention problems is some circumstances but not others. But treating it like an inability to pay attention and thus would be able to be captured and diagnosed by laboratory tests like the CPT seems like a gross misunderstanding of how this disorder works and presents, no?

By the way, much like insomnia and "Doc, I cant sleep?" this is not a real interest/passion of mine. It is NOT why I got into this field, and it would be quite boring to me if it weren't so controversial in terms of how we assess it and understand it. However, it's an area that is responsible for a disproportionate amount of psych resource utilization in this country (now my business/area of work), and I am surprised out how poorly understood and misunderstood it is by the practitioners that are suppose to be the experts on this stuff (psychologist and psychiatrists).

In residency, we didnt prescribe any controlled substances. So we didn't see much add/hd as the community knew they could not get those meds from us.

 

[clausewitz2]

My understanding is that the name is misleading and does not capture what is going on with this heterogeneous disorder...or at least its heterogeneous clinical presentation in children and adolescents?

A developmental disorder of executive functioning can lead to attention problems is some circumstances but not others. But treating it like an inability to pay attention and thus would be able to be captured and diagnosed by laboratory tests like the CPT seems like a gross misunderstanding of how this disorder works and presents, no?

By the way, much like insomnia and "Doc, I cant sleep?" this is not a real interest/passion of mine. It is NOT why I got into this field, and it would be quite boring to me if it weren't so controversial in terms of how we assess it and understand it. However, it's an area that is responsible for a disproportionate amount of psych resource utilization in this country (now my business/area of work), and I am surprised out how poorly understood and misunderstood it is by the practitioners that are suppose to be the experts on this stuff (psychologist and psychiatrists).

Re:ADHD not being an inability to pay attention globally, who on Earth familiar with the associated phenomenology ever thought this was true? I just find that baffling, having never heard this reported even in pretty obvious, uncontroversial ADHD. Flexible deployment of attention, on the other hand...

@TikiTorches no controlled Rx ever during residency? Even to kids? That seems...maybe suboptimal for training.

@PSYDR I have yet to encounter a child psychiatrist who ordered EKGs before stims without a significant family history of arrythmia. I have also never met a cardiologist who thought that even this was necessary. I think in this case you do find a concurrence between empirical base and practice, possibly because evidence favors the path of least hassle.

 

[PikminOC]

I was in adult psychiatry. So no kids. Great training. I am board certified. Kids is a fellowship training which I did not do.


I do recommend ekgs and do not do them myself. The concern is underlying cardiac defects or problems and directly related to the malpractice climate. If there is a complication, dont want to be without ekg in file.

 

[PsyDr]

@clausewitz2

I am not a pediatric guy, so my sample is extremely limited. But I do know one ped psychiatrist who does. He is paranoid about malpractice.

 

[clausewitz2]

I was in adult psychiatry. So no kids. Great training. I am board certified. Kids is a fellowship training which I did not do.


I do recommend ekgs and do not do them myself. The concern is underlying cardiac defects or problems and directly related to the malpractice climate. If there is a complication, dont want to be without ekg in file.

Also in adult psychiatry myself. ACGME requires at least 2 months FTE equivalent of treating children be part of the training curriculum for accreditation. I am curious as to how your program stayed open if you avoided kids entirely.

 

[PikminOC]

I did the kids rotation inpatient. No controlled subs that I remember there. But it was a while ago.