Psychological Testing & ADHD

[prominence]

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Do you routinely order psychological testing for all outpatients who request stimulants for ADHD (especially the patients who were never formally diagnosed with ADHD as children)?

 

[billypilgrim37]

It's easier to just prescribe Strattera and watch them never come back.

/I kid, mostly.

 

[OldPsychDoc]

It's easier to just prescribe Strattera and watch them never come back.

/I kid, mostly.

Works for me! (The not-coming-back part, I mean...)

 

[billypilgrim37]

On a more serious note, collateral from parents should probably happen before, and is much more important than, neuropsych testing. I've seen good data that adults with ADHD have essentially no insight into their behaviors as children. Neuropsych could be valuable, but it no more makes the diagnoses than a good interview looking for evidence of ADHD along mood and anxiety disorders and substance abuse and medical issues. Good interview + good collateral = diagnosis. Not to say that NP testing couldn't add something, and not that collateral mom and dad couldn't be trying to game an amphetamine script, but that's life.

I think the use of neuropsych testing is more the result of non-C&A psychiatrists not feeling comfortable actually assessing ADHD than anything, and most adult psychiatrists are just hoping the NP testing says the pt doesn't have ADHD so they can point to the paper and say, "No Concerta for you!"

 

[erg923]

One thing that has always struck me as odd when it comes to diagnosing ADHD, is that the "standard of care" is interview (parent, teacher, patient, etc.) and symptom rating scales (parent, teacher, patient, etc.). However, when the very title of the diagnosis includes at least one cognitive construct (i.e., attention), why would you NOT want an objective measures of that construct so you can truly see whether or not its dysfunctional or disordered?

Imagine a similar situation concerning dementia, particularly Alzheimer's disease. Would anyone ever accept that the best way to go about differentiaing AD from other forms of dementia is through interviews with the caregiver, patient, etc.? Is it better to make such a determination based on such subjective impressions, which we know have very low correlation with actual memory functioning, than to give actual tests of cognition and particularly memory? I think not...
By the way, yes, I am aware of experts such as Barkley that don't think neuropsych tests have enough sensitivity to provide a definitive dx. But I still maintain that an appropriate diagnostic assessment at least attempts to objectively assess the construct purported to be disordered.

Moreover, the variety of things that can be missed or could lead to erroneous diagnosis in this population based solely on parent impressions/history and simple rating scales is scary, IMHO.

It may just be me, but if someone has a fever it seems like a good idea to take a temp....?

 

[billypilgrim37]

It may just be me, but if someone has a fever it seems like a good idea to take a temp....?

Or, if all you have is a thermometer... 😉

But I'm not supremely interested in how inattentive they are. I'm interested in how the inattention affects their lives, and whether it's due to anxiety or depression or a medical condition (because, if they were perfectly fine as children, their presentation now is much more likely due to one of these things). And I'm interested in whether it fits fairly with the time course of what we think we know about ADHD. And neuropsych testing just tells me how inattentive they are. I'm not saying that couldn't be useful, but I can spend a few hundred bucks of a patient's money on lots of things that could be useful. It's not useful enough to automatically order it. But again, I'm not saying it would never be useful or appropriate or helpful.

And yes, until somebody comes along with more data and expertise on adult ADHD than Russ Barkley, we're stuck with his thinking being pretty much the best thinking out there on many aspects of adult ADHD.

Btw, his website has to be the shadiest looking thing, given that he's actually entirely legit: http://www.russellbarkley.org/index.htm. Seriously, there are probably Nigerian princes with websites that look more reliable and professional than his site.

 

[erg923]

A proper npsych eval doesn't just tell you "how much" (e.g., magnitude), it can tell you what its not and why. I am more than a tech. I can say more than "average", "low average", "mildly impaired", "moderately impaired", etc. Neuropsychologists don't get a Ph.D. and do a 2 year fellowship in neuropsychology so they can tell their referral sources attention is "impaired"..and thats it! Unfortunately, this is still how neuropsychologists are viewed in the medical psychiatric community. Paired with a good interview (which gets at timelines, psych/med hx, etc.), rating scales, and a good objective psychopathology measure (MMPI-2, MMPI-A, PAI), it can be a powerful eval.

By analyzing the pattern and magnitude of deficits, hx, and current psych/personality fucntioing, the npsych eval's ultimate goal is to tell you what is the mostly likely culprit/cause of the attentional problems (depression, anxiety, pre-existing LD, other neurodevelopmental disorders, etc), if they exist at all.

 

[billypilgrim37]

Of course you're not just a tech! That's why several hours of your time is going to cost a lot of money! And at least where I'm practicing, it's actually very difficult to find good neuropsychologists who take the insurances that most of my pts have. None of my statement was meant to devalue psychologists. It's still a clinical diagnosis, and my threshold for giving stimulants is still going to be astronomical if there's even the vaguest whiff of substance abuse or comorbidity that needs to be addressed first. So I'm not sure why I have to, every time, get another several hours of another doctoral level providers input in order to prescribe Strattera or Wellbutrin.

Btw, I would say that mostly we do differentiate the etiologies of different dementias based on clinical interview, collateral, and some bedside testing. Locally, it's MOCA and EXIT-25. If there were a neuropsychologists office who took our public insurances upstairs from every Starbucks, we might practice differently. But we're always going to be very careful about trying to mitigate vascular risk factors and screen closely for parkinsonism and time course suggestive of DLB, so again, I don't know how it's going to really change my management all that much. But again, I'm not saying it's not valuable, and if we can find a provider who will take the pt's insurance, giddy-up neuropsych. In the case of dementias, NP does help us dictate very important psychosocial interventions, risk stratifying, and identifying intact strengths, so again, I'm not saying it wouldn't be helpful, but it's not a necessity.

 

[whopper]

I am willing to prescribe the nonstimulants (Wellbutrin, Effexor, Clonidine, Strattera) for AD/HD based on the DSM criteria and a clinical diagnostic interview and without the psychological testing and EKG.

I will only prescribe a stimulant based medication such as Adderall if the person had an EKG, psychological testing, and was tried on a nonstimulant medication first.

I wrote a pamphlet for my patients explaining why I want a higher standard in the prescription of a stimulant because I found myself giving the canned "speech" over and over and over and over and over and over again several times.

 

[Suedehead]

I wrote a pamphlet for my patients explaining why I want a higher standard in the prescription of a stimulant because I found myself giving the canned "speech" over and over and over and over and over and over again several times.

hmm, i'd like to get my mitts on said pamphlet.

 

[whopper]

I made it myself in about 15 minutes. It's just a summary of the side effects and problems with stimulants such as amphetamines and the problems with misdiagnosis with ADHD.

I also explained that I absolutely demand psychological testing and an EKG and why. Trust me, you can make one yourself very quickly. I could email you one if you send me your email via PM.

 

[MLT2MT2DO]

I am willing to prescribe the nonstimulants (Wellbutrin, Effexor, Clonidine, Strattera) for AD/HD based on the DSM criteria and a clinical diagnostic interview and without the psychological testing and EKG.

I will only prescribe a stimulant based medication such as Adderall if the person had an EKG, psychological testing, and was tried on a nonstimulant medication first.

I wrote a pamphlet for my patients explaining why I want a higher standard in the prescription of a stimulant because I found myself giving the canned "speech" over and over and over and over and over and over again several times.

No LFTs for Strattera? Or am I just one of the lucky rare ones that ended up with hepatitis like enzymes from this medication?

 

[prominence]

I am willing to prescribe the nonstimulants (Wellbutrin, Effexor, Clonidine, Strattera) for AD/HD based on the DSM criteria and a clinical diagnostic interview and without the psychological testing and EKG.

I will only prescribe a stimulant based medication such as Adderall if the person had an EKG, psychological testing, and was tried on a nonstimulant medication first.

I wrote a pamphlet for my patients explaining why I want a higher standard in the prescription of a stimulant because I found myself giving the canned "speech" over and over and over and over and over and over again several times.

do you typically bypass your psychological testing requirement if you are later able to obtain documented records verifying that another provider prescribed the pt a stimulant at some point in the past? I ask this because there are some physicians who dispense stimulants and benzos like candy.

 

[whopper]

do you typically bypass your psychological testing requirement if you are later able to obtain documented records verifying that another provider prescribed the pt a stimulant at some point in the past? I ask this because there are some physicians who dispense stimulants and benzos like candy.

If I can get psychological testing from another source, I'll accept that. In general, I've been favoring the TOVA test because some of the tests IMHO are no better than the DSM. IMHO EVERYONE has ADHD based on the DSM.

Have you ever had trouble handing in homework assignments?
Have you ever wanted to get up out of your seat during class?
Have you ever fidgeted or squirmed in your seat?

Correction: I will order an EKG for Strattera. It can adversely affect the heart. I had a patient who on day 2 of that medication, the HR went to 160.

 

[Therapist4Chnge]

Btw, his website has to be the shadiest looking thing, given that he's actually entirely legit: http://www.russellbarkley.org/index.htm. Seriously, there are probably Nigerian princes with websites that look more reliable and professional than his site.

TRUE.

 

[Manicsleep]

I made it myself in about 15 minutes. It's just a summary of the side effects and problems with stimulants such as amphetamines and the problems with misdiagnosis with ADHD.

I also explained that I absolutely demand psychological testing and an EKG and why. Trust me, you can make one yourself very quickly. I could email you one if you send me your email via PM.

15 minutes?

I can't imagine a forensics person doing anything in 15 minutes because all that stuff is discoverable.

I am guessing you did a pretty thorough job. I know it would take me while before I actually put it out. I would like to see it as well.

 

[Manicsleep]

One thing that has always struck me as odd when it comes to diagnosing ADHD, is that the "standard of care" is interview (parent, teacher, patient, etc.) and symptom rating scales (parent, teacher, patient, etc.). However, when the very title of the diagnosis includes at least one cognitive construct (i.e., attention), why would you NOT want an objective measures of that construct so you can truly see whether or not its dysfunctional or disordered?

Imagine a similar situation concerning dementia, particularly Alzheimer's disease. Would anyone ever accept that the best way to go about differentiaing AD from other forms of dementia is through interviews with the caregiver, patient, etc.? Is it better to make such a determination based on such subjective impressions, which we know have very low correlation with actual memory functioning, than to give actual tests of cognition and particularly memory? I think not...
By the way, yes, I am aware of experts such as Barkley that don’t think neuropsych tests have enough sensitivity to provide a definitive dx. But I still maintain that an appropriate diagnostic assessment at least attempts to objectively assess the construct purported to be disordered.

Moreover, the variety of things that can be missed or could lead to erroneous diagnosis in this population based solely on parent impressions/history and simple rating scales is scary, IMHO.

It may just be me, but if someone has a fever it seems like a good idea to take a temp....?

LPs for ADHD?

 

[whopper]

I can't imagine a forensics person doing anything in 15 minutes because all that stuff is discoverable.

Heh...

It didn't take long mostly because I just had to copy and paste info from sources such as WebMD.

 

[billypilgrim37]

15 minutes?

I can't imagine a forensics person doing anything in 15 minutes

Is it a bad thing that I found that to be the funniest, most fundamentally true and universal statement ever made? The countertransference, it brews.

We have some forensics folks who do most of their clinical work in our ED who are so conservative with their management that they make Fox News look left of Mao's little red book.

 

[Therapist4Chnge]

Is it a bad thing that I found that to be the funniest, most fundamentally true and universal statement ever made? The countertransference, it brews.

We have some forensics folks who do most of their clinical work in our ED who are so conservative with their management that they make Fox News look left of Mao's little red book.

 

[IT514]

I know a few people in the Barkley camp and others who think hes FOS when it comes to his research on the incremental validity of a NP evaluation. My opinion is that his conclusion is off base and not entirely logical. This is after taking a course on ADHD assessment by someone who LOVES Barkley. I've assessed a lot of kids on meds who have been given a diagnosis of ADHD, only to find that they have a learning disorder or something else that explains both why they suck at school and why the meds arent working. What sucks is that the evals come 1-2 years after the ADHD Dx and they are a lot more behind in school than they should be even with the LD. To me, ADHD is a disorder of comorbidity, so I will always want to test. As far as parent rating scales go, you can use them as long as you know that many things other than ADHD will drive up those scales.

To be fair, I havent seen those kids who see a physician, get a prescription without being referred for testing, and its working for them. I really have no problem with that in a case where the parents and teachers are completely miserable and there is no evidence for something else going on. I just assume that the physician is aware of the comorbidity rates and developmental trajectory of things that look like ADHD but are not, especially in younger kids. Just like I assume that when someone gives an MMSE, they know that a score of 28 and no evidence of decline from collateral does not mean that the patient does not have dementia b/c its sensitivity to mesial-temporal functioning is questionable.

Btw, there is someone better than Barkley...James Hale. Here are a few citations for those who care:

Hale, J. B., Reddy, L. A., Semrud-Clikeman, M., Hain, L., Whitaker, J., Morley, J., Lawrence, K., Smith, A., & Jones, N. (in press). Executive impairment determines ADHD medication response: Implications for academic achievement. Journal of Learning Disabilities.

Hale, J. B., Reddy, L. A., Wilcox, G., McLaughlin, A., Hain, L., Stern, A., Henzel, J., & Eusebio, E. (2009). Assessment and intervention for children with ADHD and other frontal-striatal circuit disorders. In D. C. Miller (Ed.), Best practices in school neuropsychology: Guidelines for effective practice, assessment and evidence-based interventions (pp. 225-279). Hoboken, NJ: John Wiley & Sons.

Hale, J. B., Reddy, L. A., Decker, S. L.,Thompson, R., Henzel, J., Teodori, A., Forrest, E., Eusebio, E., Denckla, M. B. (2009). Development and validation of an executive function and behavior rating screening battery sensitive to ADHD. Journal of Clinical and Experimental Neuropsychology, 31, 897-912.

 

[hippiedoc13]

I am willing to prescribe the nonstimulants (Wellbutrin, Effexor, Clonidine, Strattera) for AD/HD based on the DSM criteria and a clinical diagnostic interview and without the psychological testing and EKG.

I will only prescribe a stimulant based medication such as Adderall if the person had an EKG, psychological testing, and was tried on a nonstimulant medication first.

I wrote a pamphlet for my patients explaining why I want a higher standard in the prescription of a stimulant because I found myself giving the canned "speech" over and over and over and over and over and over again several times.

That is awesome. And when I say that, I mean the high threshold for stimulants, the clearly communicated stepwise progression, and the fact that you have a written handout for it. I am a big handouts person. 😍

Unfortunately most of my experience with adults seeking treatment for "ADHD" has been with (a) folks looking to score stimulants legally for, ahem, recreational purposes; or (b) college students with no actual functional impairment who are looking for a cognitive boost from stimulants (some would call this 'cosmetic psychiatry'.) Unfortunately that has led me to be quite skeptical when someone comes in telling me they have ADHD, so I do a pretty careful diagnostic interview and get collateral. I do not prescribe stimulants on the first visit. I recognize that I have been biased by the pt experiences I've had in the past, but it is what it is.

As a practical issue, in my practice setting, I haven't yet sent anyone for neuropsych testing to eval for ADHD. Neuropsych testing is relatively available in our training setting. And I agree with billypilgrim that neuropsych testing can be a valuable component of evaluations for many types of patients. But so far, in the cases of "is this ADHD, should we prescribe stimulants?" that I have seen, the historical and collateral data pretty much sealed the deal about whether I was going to prescribe stimulants or not, and neuropsych testing probably would not have changed my clinical decision-making one way or the other, so it didn't seem like a good use of that resource.

 

[whopper]

Out of all my patients on a medication that could be used as a substance of abuse that was started on the medication by another doctor....

With the exception of one attending I had in residency that sometimes treated my patients...

Not one of my patients when asked told me their previous doctor alerted them to the possible dangers of the medications (e.g. dependence, addiction, tolerance, cardiac problems).

Not one of my patients when asked told me their previous doctor had a plan to give out the medications only temporarily because the long term problems that could happen with those medications.

Out of those patients (and this is completely anectdotal, I never tallied it up in a study), about 1/3 of them had their medications raised in a step-wise manner. E.g. they were put on Ativan 1 mg Qdaily. Then gradually it just went up and up. The worst case I saw was the patient was on Ativan 6 mg a day, Klonopin 6 mg a day, and Xanax (forgot the dose).

Private market forces actually encourage doctors to do such practice. In private practice, doctors get more money if they see patients quicker, putting a disincentive to spend time and educate patients. Further, if a patient is addicted to a medication, that only garauntees their continued compliance to show up and make more money for the doctor.

I've had a subset of patients after one meeting refuse to see me again because their previous doctor put them on an amphetamine and a benzodiazapine. I tell the patient that my goal is over the course of several months, wean them off the benzodiazapine while trying to get whatever problem the benzo was treating (if that---the patient may have simply been getting high off the med thanks to their previous doctor) treated with a different medication such as an SSRI. I also tell them the possible dangers with a stimulant medication, and that I need to be certain if the really need to be on it.

The worst case that happened was a patient in the office started screaming at me demanding an amphetamine without psychological testing. After several attempts to explain to her why I need that testing that's when she stood up and started screaming. She said a previous doctor gave her an ADHD dx, and I checked out that doctor's notes. He was, ahem, a quack. Trust me. If you worked in my parts you'd know I was right. This guy was actually in the newspapers several times for giving patients rectal exams even though he was a psychiatrist and there was no reason for him to do so.

Of course I did consider that the fact that she was screaming a possible sign that she did in fact have ADHD or some other disorder, but I will not give an amphetamine out unless there's testing backing the person has ADHD, an EKG, and a nonstimulant is tried.

I told the patient the groundrules and then flatly laid out that she could try to find another psychiatrist if she did not like my method of practice.

The most recent "bad case" was I had a new patient who as put on Focalin to treat depression. He was never told by the previous doctor of the possible dangers with the medication, and that it isn't really a first, second, third or even fourth choice medication for depression. He was showing several signs of being addicted to the medication. E.g. "Doc, this is the best medication I've taken! It makes me feel so good! I can't live without it!" He also had paranoid personality disorder which IMHO just made the decision to give him Focalin not just out of the ordinary but on the bounds of stupid. I requested he give me the previous doctor's records, but the patient refused, and then told me that he believed I was part of some conspiracy.

After several demands to stay on the Focalin, I told him I never intended to stop it cold turkey, but to put him on an antidepressant while I gradually weaned him off of Focalin over the course of at least 6 months.

I never saw the guy again but he continues to show up to the same office to see my boss (a psychologist) right next door to me. I discussed that case with the psychologist and we're both of the opinion that the Focalin is the last thing this guy needs. In fact it's likely making his paranoia which was already bad before he was on it--worse.

 

[Regnvejr]

If I, as a trained C&A psychiatrist cannot recognize the symptoms of ADHD in anyone who have it, I slept through my fellowship.

That aside, many of my adults with attention problems leave the first couple of clinic visits with at best a Rule-Out diagnosis. First, are the sleeping well enough to be alert, is their stress level so high that they don't have a chance to focus, and so on. And even if they clearly have ADHD/ADD, there is no way I treat this until their general stress level is controlled.

Frankly, if you place a stressed, overwhelmed and unfocused patient on ADHD meds, the first thing they experience is a serious increase in focus on.....their own stress. They start feeling worse.

 

[Regnvejr]

No LFTs for Strattera? Or am I just one of the lucky rare ones that ended up with hepatitis like enzymes from this medication?

That happens to about 1 in 1.2 mill. Testing is recommended only if symptoms appear.

 

[Regnvejr]

On a more serious note, collateral from parents should probably happen before, and is much more important than, neuropsych testing. I've seen good data that adults with ADHD have essentially no insight into their behaviors as children. Neuropsych could be valuable, but it no more makes the diagnoses than a good interview looking for evidence of ADHD along mood and anxiety disorders and substance abuse and medical issues. Good interview + good collateral = diagnosis. Not to say that NP testing couldn't add something, and not that collateral mom and dad couldn't be trying to game an amphetamine script, but that's life.

I think the use of neuropsych testing is more the result of non-C&A psychiatrists not feeling comfortable actually assessing ADHD than anything, and most adult psychiatrists are just hoping the NP testing says the pt doesn't have ADHD so they can point to the paper and say, "No Concerta for you!"

You can spend unwarranted amounts of money on testing because you are convinced that anyone with ADHD symptoms are a drug-seeking scoundrel. but patients are not our enemies. We are supposed to have clinical skills, after all. Add a few extra questions that go beyond the DSm, and the ones with ADHD will answer in a meaningful fashion, while the malingerers will get thrown off track, get confused and their answers don't make sense, or seem contrived.

Ask them how they feel if they get interrupted. The ADHD patients will say they get irritated, the malingerers will be afraid of coming across as aggressive, and say something else.

Ask them what the clocks are set at at home. With ADHD, time gets lost, and the clocks are set 5-15 minutes ahead. The ones without that problem will have no clue what you mean.

 

[Regnvejr]

...However, when the very title of the diagnosis includes at least one cognitive construct (i.e., attention), why would you NOT want an objective measures of that construct so you can truly see whether or not its dysfunctional or disordered?

Part of it is that something is a disorder when it bothers the patient's life. We don't treat the test.

 

[Regnvejr]

I am willing to prescribe the nonstimulants (Wellbutrin, Effexor, Clonidine, Strattera) for AD/HD based on the DSM criteria and a clinical diagnostic interview and without the psychological testing and EKG.

Aren't you then under-treating?

I will only prescribe a stimulant based medication such as Adderall if the person had an EKG, psychological testing, and was tried on a nonstimulant medication first.

EKG really is only indicated if the patient ever had an arrhythmia, psychological testing frankly doesn't say that much about ADHD, only about symptom changes over time. As for the non-stimulant, that may or may not be indicated, but Clonidine gives you at best 25% symptom relief, Strattera in adults give you somewhere about 50-70% relief, they never really get to the patient's full potential. What you CAN do with Strattera is to augment your stimulant to get better effect at lower doses and therefore with less side effects.

I wrote a pamphlet for my patients explaining why I want a higher standard in the prescription of a stimulant because I found myself giving the canned "speech" over and over and over and over and over and over again several times.

Which raises the question of whether your patient population is more of the forensic population, or the ones who really can't focus who suffer family and employment complications from ADHD.

My biggest frustration when I get patients in the door is when past psychiatrists have under-treated patients.

 

[erg923]

Part of it is that something is a disorder when it bothers the patient's life.

Well, yea, but doesn't mean its AD/HD. Not every subjective complaint (attention or otherwise) warrants or qualifies as a diagnosis/disorder.

 

[whopper]

but patients are not our enemies. We are supposed to have clinical skills, after all. Add a few extra questions that go beyond the DSm, and the ones with ADHD will answer in a meaningful fashion, while the malingerers will get thrown off track, get confused and their answers don't make sense, or seem contrived.

When I explain why I don't want the person on a stimulant, the person I've noticed is actually open to trying some of the less extreme treatments for ADHD.

I tell the patient this...
1) Stimulants can cause heart problems among several other possible problems. This leads to why I want them to have an EKG.
2) If stabilized with a nonstimulant, I don't have to see the patient as often. I wasn't aware of this until it happened, but several pharmacies at least in my state will not allow me to order refills on stimulants. The doctor won't have to see me as much if stable if on a nonstimulant.
3) I give them that handout I mentioned above on the benefits and risks of stimulants.

So far, at least in private practice, I've had several more patients I've given stimulants vs. state-run/non-profit community practice. Why? I'm not exactly sure but I'm getting the impression it's because those in private practice actually have gone through the hoops I've mentioned. In community practice, several refused to do the testing, or the testing did not support that they had AD/HD. At the community center where I worked last academic year, it was actually easier for them to get the EKG and testing than it is in private practice because we had an EKG machine on the premises and a nurse was usually available to do the testing before or after I saw the patient.

Actually this has been a pain in the butt in private practice because I will not give the medication out without the necessary safeguards and education, and in private practice, getting the patient in and out the door is what makes the money. So I'm essentially putting myself in a situation where I'm making less money than I would in community practice by taking the time to educate the patient on ADHD.

 

[Regnvejr]

Well, yea, but doesn't mean its AD/HD.

*sigh* When you have diagnostic symptoms, and your life is not impacted, then there is no need to treat. If you have diagnostic symptoms and you can't function because of the symptoms, then you treat. It is really that simple. What you treat with is another story, but if you always expect every patient to be an addict, then you end up undertreating most of your patients.

Not every subjective complaint (attention or otherwise) warrants or qualifies as a diagnosis/disorder.

Did I actually claim that? 🙄

 

[Regnvejr]

When I explain why I don't want the person on a stimulant, the person I've noticed is actually open to trying some of the less extreme treatments for ADHD.

Hmm, what is an "extreme" treatment? That sounds a lot like the lawyers talking about patients being on a "powerful" antipsychotic.

I tell the patient this...
1) Stimulants can cause heart problems among several other possible problems.

So you tell them the large increase in risk for substance use, traffic accidents, get run down in intersections, accidents in the home etc in untreated ADHD?

This leads to why I want them to have an EKG.

And have you checked up how much an EKG cost, and the need-to-treat data? That's why LFT is not recommended for Strattera any more.

2) If stabilized with a nonstimulant, I don't have to see the patient as often. I wasn't aware of this until it happened, but several pharmacies at least in my state will not allow me to order refills on stimulants.

Stimulants are generally class II. But the patient doesn't need to actually see you to get the follow-up scripts. And you can write 3 scripts at a time, works the same as refills.

The doctor won't have to see me as much if stable if on a nonstimulant.

No more than if they are stable on a stimulant. For adults, the vast majority of time, non-stimulants are under-treating ADHD.

3) I give them that handout I mentioned above on the benefits and risks of stimulants.

How much do you educate them about ADHD?

So far, at least in private practice, I've had several more patients I've given stimulants vs. state-run/non-profit community practice. Why? I'm not exactly sure but I'm getting the impression it's because those in private practice actually have gone through the hoops I've mentioned. In community practice, several refused to do the testing, or the testing did not support that they had AD/HD.

What did their symptoms show?

At the community center where I worked last academic year, it was actually easier for them to get the EKG and testing than it is in private practice because we had an EKG machine on the premises and a nurse was usually available to do the testing before or after I saw the patient.

How much did they have to pay for the EKG? Unless there is known cardiac history or symptoms, EKGs are a needless extra test in these cases.

Actually this has been a pain in the butt in private practice because I will not give the medication out without the necessary safeguards and education, and in private practice, getting the patient in and out the door is what makes the money. So I'm essentially putting myself in a situation where I'm making less money than I would in community practice by taking the time to educate the patient on ADHD.

You always have to educate your patients. If they don't understand their disorders and how the meds work, they really can't report the effect back on you, and that's bad medicine.

 

[erg923]

*sigh* When you have diagnostic symptoms, and your life is not impacted, then there is no need to treat. If you have diagnostic symptoms and you can't function because of the symptoms, then you treat. It is really that simple. What you treat with is another story, but if you always expect every patient to be an addict, then you end up undertreating most of your patients.
Did I actually claim that? 🙄

The original question was regarding the neuropsychological assessment and diagnosis of AD/HD for treatment purposes. I'm not a psychiatrist, so I was not contributing to the debate on what gets treated and what doesn't. I was simply arguing proper diagnostics from a neuropsychological approach/view of the disorder.

Contrary to the mode of intervening first that has emerged in our education system (trial and error as far as I'm concerned), as a diagnostician, I firmly believe good/proper treatment comes from good assessment.

 

[whopper]

All very good points Regnvegr. Unfortunately, so many questions in one post.

I referred to stimulants as a more "extreme" treatment without giving a precise definition. I call them more extreme becuase in addition to having higher efficacy, there's also increased risks and they are controlled substances.

As for the writing of the scripts, it may be a different thing between states, I don't know, but several times when I've written for stimulants for more than a month, the pharmacy will not honor that script. I believe I already mentioned that.

As for the details you mentioned, such as the increased use of substances while on a stimulant, I do also make those known the patient as well, in addition to plenty of other data.

E.g. I get several patients where they look like something of a messy mix of AD/HD, bipolar, generalized anxiety disorder, and/or borderline PD. In some of these cases, it's hard to figure out what it is. If you give a bipolar disordered patient a stimulant, you can risk pushing them into mania. I bring that issue up as well.

As for the patients where psychological testing did not show they had AD/HD, their signs and symptoms have run a very large spectrum where it could've been a number of different problems. They ran the entire spectrum of disorders I mentioned in the previous paragraph, but also included substance abuse and dependence.

As for the EKG, in my private practice, the overwhelming majority of patients were able to afford them without a problem and had private insurance. In my community based practice, the overwhelming majority didn't have to pay for the EKG and it was provided on-the-spot.

 

[erg923]

Just to add to the point whopper made about finding other issues/diagnosis when reffered for testing....this is also my experience.

Does the person have a processing deficit (or a phonological processing disorder) as opposed to an attention disorder? Is the person a high verbal great reader but has difficulty with the output and organizational demands of writing. Do they really have an arithmetic disorder? Or is the person not ADHD at all, but someone who has nonverbal learning disorder? Some of the presenting complaints can be very much the same… disorganization, not completing certain tasks, aloof or seemingly distracted, careless errors…. Is their sloppy handwriting part of a co-existing coordination disorder, which if untested fails to provide recommendations for accommodations or pediatric OT. I think it is important to at least attempt to tease out all these things if an individual presents to your office complianing of "attention problems." I take my patients' compliants seriously, but I'm also not foolish enough to believe that their perception of what is wrong (or disordered), is actually always the thing that is truely disordered. It might not be attention at all. The best way to find out, IMHO, is to objectively test the persons cognitive functions by refering them for a comprehensive neuropsych eval. Which, by they way, is different from mere "psychological testing" that everyone keeps referring to. I think there may be confusion between neuropsychological "testing" and "neuropsychological "assessment." One is simply a score on a test, the other is process of data intergration (a large part of which is psychometric test data) in order to arrive at a conclusion about diagnosis and etiology for purposes of treatment planning. What I'm refering to is the latter, not the former.

The reason I stress this, Regnvejr, is simple. I have see patients of all ages with diagnoses of "AD/HD" in their chart. Most have multiple complexities to begin with, including some combination of the effects of extreme poverty, poor parenting, childhood abuse, possible lead exposure, head injuries, possible LDs, a variety of psychiatric illnesses with at least one hospitalization, in-home support services, family history of all sorts of psychiatric and possibly genetic problems, and so on. They are having multiple very concerning symptoms/behaviors that bewildered physicians, case managers, parents (if a child), psychiatrists, and/or therapists. Unfortunately, these are inevitably summed up as "ADHD." Without a proper diagnostic work-up (and differential diagnostic exclusions), you are potentially creating a disorder for them that they simply do not have (fostering even more disability and disorder in this population is never a good thing), and potentially missing the actual root cause of their complaint.

 

[whopper]

The best way found out, IMHO, is to objectively test the persons cognitive functions by refering them for a comprehensive neuropsych eval.

Bipolar disorder: distractibility, doing too many things at once and not being able to finish any of them, irritability

Depression: decreased ability to concentrate and remember

Generalized anxiety disorder: irritability, feeling "keyed up", restlnessness, difficulty concentrating

Borderline PD: impulsive acts, affective instability, inappropriate anger

All of the above symptoms from each of the disorders could make it look like ADHD. Further ADHD is often comorbid with the above disorders.

It's not uncommon for someone to fall in that unfortunate zone where they can look like they have everything when in fact they only have one disorder..

E.g. person has problems sleeping, is easily angered, abuses drugs, feels keyed up, has difficulty concentrating, has low self esteem which may or may not be related to years of poor academic performance. Just what the heck is that? I don't know. It could be any of the above including AD/HD.

That's why I want psychological testing. IMHO everyone has AD/HD based on the DSM-IV criteria. At least testing may shed some light. It could also decrease the time in the "guinea pig" phase where we try meds on a person and it turns out it's not the right med because we don't have the right diagnosis.

 

[Regnvejr]

All very good points Regnvegr. Unfortunately, so many questions in one post.

I referred to stimulants as a more "extreme" treatment without giving a precise definition. I call them more extreme becuase in addition to having higher efficacy, there's also increased risks and they are controlled substances.

And most of the time less side effects. Strattera is not exactly well-tolerated, needs titration etc.

As for the writing of the scripts, it may be a different thing between states, I don't know, but several times when I've written for stimulants for more than a month, the pharmacy will not honor that script. I believe I already mentioned that.

As far as I know, it is federal law for Schedule II compounds.

As for the details you mentioned, such as the increased use of substances while on a stimulant, I do also make those known the patient as well, in addition to plenty of other data.

Actually, I was pointing out that the substance risk increase OFF stimulants. So does the risk of accidents.

E.g. I get several patients where they look like something of a messy mix of AD/HD, bipolar, generalized anxiety disorder, and/or borderline PD. In some of these cases, it's hard to figure out what it is. If you give a bipolar disordered patient a stimulant, you can risk pushing them into mania. I bring that issue up as well.

Absolutely. In such a scenario, the ADHD must remain a rule-out diagnosis until the mood disorders are controlled. After all, mood disorders can give ADHD symptoms (though typically not enough to fit the entire diagnostic requirement).

As for the patients where psychological testing did not show they had AD/HD,

What testing do you use?

their signs and symptoms have run a very large spectrum where it could've been a number of different problems. They ran the entire spectrum of disorders I mentioned in the previous paragraph, but also included substance abuse and dependence.

So then ADHD remains a rule-out diagnosis, right?

As for the EKG, in my private practice, the overwhelming majority of patients were able to afford them without a problem and had private insurance. In my community based practice, the overwhelming majority didn't have to pay for the EKG and it was provided on-the-spot.

The private insurances covered this?

Also, since you must now have a good database on this, how many problems were discovered without preceding clinical history? I have never been able to find good data on this.

 

[erg923]

Would just like to quickly point out that there is differeence between "neuropsychological testing" that everyone keeps referring to and a neuropsychological "assessment/evaluation". One is simply a score on a test, the other is process of data intergration (a large part of which is psychometric test data) in order to arrive at a conclusion about diagnosis and etiology for purposes of treatment planning. What I'm refering to is the latter, not the former.

 

[Regnvejr]

....The reason I stress this, Regnvejr, is simple. .....

Ok, this is beginning to sound condescending like I was a medical student or something, so I will bow out of this before I say something to you that I will regret. I recommend you do the same.

 

[erg923]

Um, no, Im not gonna bow out from advocating my point of view and approach, and neither should you frankly. Im simply giving the other dicipline's perspective, not meant to be condesending...

I would encourage you to retort, I'm interested in your (and other psychiatrists) perceptions and views on this.

 

[Regnvejr]

Um, no, Im not gonna bow out from advocating my point of view and approach, and neither should you frankly. Im simply giving the other dicipline's perspective, not meant to be condesending...

I would encourage you to retort, I'm interested in your (and other psychiatrists) perceptions and views on this.

You are further confirming that if I continue with you, the outcome is unhappy. So we are done.

 

[erg923]

And you are furthering confirming that you're avoiding the issues I raised...so be it.

PS: Discussion board threads shouldn't make you unhappy.😀