Stimulants in Outpatient

[zenmedic]

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How are you all going about treating ADHD and writing for stimulants in outpatient/private practice? In my clinic I have attendings who 1) never prescribe stimulants no matter what, 2) require neuropsych testing first, or 3) fine with starting (usually just DSM criteria, other psych conditions controlled, and no red flags). I have heard many private practice psychiatrists have a no benzo no stimulants policy. Wondering how all of you got about it considering my only experience so far is in the context of residency (PGY-3). Thanks!

 

[splik]

How are you all going about treating ADHD and writing for stimulants in outpatient/private practice? In my clinic I have attendings who 1) never prescribe stimulants no matter what, 2) require neuropsych testing first, or 3) fine with starting (usually just DSM criteria, other psych conditions controlled, and no red flags). I have heard many private practice psychiatrists have a no benzo no stimulants policy. Wondering how all of you got about it considering my only experience so far is in the context of residency (PGY-3). Thanks!

It is almost impossible to have a no controlled subs policy if you want to have a successful cash private practice. It is also quite rigid if patients would actually benefit from such medications. The psychiatrists who do that, have like 20 state licenses, and still need side gigs to pay the bills.

Things to remember are:
1. There is an hysterical epidemic of ADHD. Only about 1 in 4 pts who think they have ADHD actually have ADHD.
2. If patient do have ADHD (which is typically comorbid with other conditions including autism, OCD, Tourette's, SUDs, anxiety, depression, bipolar, personality disorders, learning difficulties), it is eminently treatable in many cases.
3. Stimulants are the first line drug treatment for ADHD. Unless there is some contraindication, it is a departure from the standard of care NOT to prescribe stimulants.
4. Malingering ADHD is common. Stimulant seeking is common. Diagnosis seeking is common. Diversion is common. Many psychiatrists feel uncomfortable with this and thus might refuse to rx stimulants or request blanket neuropsych testing on everyone which is impractical and overkill.
5. Differential diagnosis includes anxiety disorders, PTSD, developmental trauma, personality disorders (especially borderline, narcissistic and antisocial), sleep disorders (including OSA, sleep insufficiency, insomnia), TBI, chronic pain syndromes, fibromyalgia, substance use disorders (especially cannabis or stimulant use disorders).

suspected "adult" ADHD is one of the most common, if not the most common reason for psychiatric consultation today.

In my practice, I actually avoid ADHD consults for the most part but if someone has ADHD as part of the constellation I will assess and treat as appropriate. In addition to a comprehensive developmental and psychiatric history, I use the DIVA-5, ASRS, WURS, and BDEFS to assess for ADHD. collateral is very helpful where available. If patients are using their benefits, I tell them it will take multiple appts to complete the assessment and discuss a treatment plan.

 

[zenmedic]

It is almost impossible to have a no controlled subs policy if you want to have a successful cash private practice. It is also quite rigid if patients would actually benefit from such medications. The psychiatrists who do that, have like 20 state licenses, and still need side gigs to pay the bills.

Things to remember are:
1. There is an hysterical epidemic of ADHD. Only about 1 in 4 pts who think they have ADHD actually have ADHD.
2. If patient do have ADHD (which is typically comorbid with other conditions including autism, OCD, Tourette's, SUDs, anxiety, depression, bipolar, personality disorders, learning difficulties), it is eminently treatable in many cases.
3. Stimulants are the first line drug treatment for ADHD. Unless there is some contraindication, it is a departure from the standard of care NOT to prescribe stimulants.
4. Malingering ADHD is common. Stimulant seeking is common. Diagnosis seeking is common. Diversion is common. Many psychiatrists feel uncomfortable with this and thus might refuse to rx stimulants or request blanket neuropsych testing on everyone which is impractical and overkill.
5. Differential diagnosis includes anxiety disorders, PTSD, developmental trauma, personality disorders (especially borderline, narcissistic and antisocial), sleep disorders (including OSA, sleep insufficiency, insomnia), TBI, chronic pain syndromes, fibromyalgia, substance use disorders (especially cannabis or stimulant use disorders).

suspected "adult" ADHD is one of the most common, if not the most common reason for psychiatric consultation today.

In my practice, I actually avoid ADHD consults for the most part but if someone has ADHD as part of the constellation I will assess and treat as appropriate. In addition to a comprehensive developmental and psychiatric history, I use the DIVA-5, ASRS, WURS, and BDEFS to assess for ADHD. collateral is very helpful where available. If patients are using their benefits, I tell them it will take multiple appts to complete the assessment and discuss a treatment plan.

Thanks that's very helpful. I haven't heard of the DIVA-5, WURS, and BDEFS. ASRS and DSM criteria are what I've been using but I'll read up on the others.

 

[comp1]

Neuropsych testing is pointless. It's almost diagnostic that the patient doesn't have ADD if they can actually follow through with scheduling and completing it without issue. If a person wants to feign ADD, they will feign it, either on testing or during a clinical interview. I don't believe any of the neuropsych tests for ADD even have validity scales like personality assessments. ADD should have a long term historical course beginning in childhood (not grad school). It may or may not have been treated, but it should have been at least somewhat impairing. I focus on distant history during interviews and collect collateral wherever possible. It's also a time to actually use your MSE skills as opposed to letting the patient self check the DSM boxes. It's important conceptually that unlike what SSRIs or antipsychotics treat, stimulants will improve EVERYONE'S focus, regardless of whether they have ADD or not.

 

[Bartelby]

I agree that neuropsych testing is not needed. Many neuropsychologists will bounce back such referrals.

I recommend:
1- identify whether any other disorder (significant depression, anxiety, etc) is present. This includes recurrent substance use even if it does not clearly meet SUD criteria. If present, optimize management of that first before deciding whether ADHD is present. This includes a trial of abstinence from any substances of abuse.

If still a concern and the self-reported patient history is consistent with ADHD then get either:

1- reliable past records that support an ADHD diagnosis. The gold standard would be something like a real ADHD assessment from childhood by a child psychiatrist or psychologist. If the past records look like, for example, seeing an NP through a telehealth pill mill I would not give them much weight.

OR

2- a collateral interview with someone who knew the patient well growing up, typically a parent unless there is some clear reason they are not suitable (for example, the parent was abusive and the patient is not in contact with them anymore).

If the patient passes those checks then I make the diagnosis and will prescribe stimulants unless there is some contraindication, or patient preference for another approach like CBT or non-stimulants. I think this balances acknowledging and treating real illness with avoiding over prescribing controlled substances / completely relying on what the patient tells you.

 

[Stagg737]

Thanks that's very helpful. I haven't heard of the DIVA-5, WURS, and BDEFS. ASRS and DSM criteria are what I've been using but I'll read up on the others.

ASRS is garbage. It's the "valid" screening tool I see used most often and also the one that I see completely miss the actual diagnosis the most by far. It's fine for a quick screen, but I absolutely would not diagnose just based on that.

I like the DIVA and ACE+ as they really dig into the developmental aspects and they ask for specific examples of positive responses, so you can get an idea of the severity of the dysfunction and how it could actually be affecting the person in day to day life. The problem is that these are longer tools that require a lot more time and people don't want to take the time to administer them. I like the ACE better because the examples are given but the interviewer is instructed specifically NOT to read the examples to patients whereas the DIVA says to give the patients examples if they can't come up with any on their own (increased chance of malingering).

The WURS is fine, but most people just use the total score of the WURS and assume that it's going to be highly valid results without knowing the WURS actually has built-in subscales. I sometimes use this but also look at the specific subscales (ADHD-specific symptoms, conduct d/o related symptoms, mood/anxiety symptoms) to see where the actual reported symptomatology is most prevalent. I've had more than a few patients meet the positive cutoff for ADHD but have the majority of their reported symptoms fall under the mood and conduct scales with almost not positives in the ADHD scale. Guess what happened when we started SSRIs instead of stimulants...

The full Barkley scale (BDEFS) is one you're probably not going to see many psychiatrists using, as it's not specific for ADHD but is also a longer form (something like 90 items) that is more time consuming. The only person I know that uses the scale is a cognitive neurologist (neuropsych in our world) but he uses it for TBI evals. You might see people using the BAARS-IV, but this is similar to the ASRS and basically just runs through the DSM criteria.

As others have said, it's essential to get a developmental picture and sometimes the best way to get an accurate history is to ask a spouse or roommate. It's also essential to rule out other issues as the cause of "ADHD symptoms", as there are many patients, probably the vast majority, who do not need ADHD treatment and get better when their other issues are addressed.

 

[Stagg737]

How are you all going about treating ADHD and writing for stimulants in outpatient/private practice? In my clinic I have attendings who 1) never prescribe stimulants no matter what, 2) require neuropsych testing first, or 3) fine with starting (usually just DSM criteria, other psych conditions controlled, and no red flags). I have heard many private practice psychiatrists have a no benzo no stimulants policy. Wondering how all of you got about it considering my only experience so far is in the context of residency (PGY-3). Thanks!

To answer your OP, I almost never start stimulants. However that's more of a function of my clinic being a consultation clinic and not a typical continuity clinic. My approach is similar to Splik's in that I have generally stopped taking ADHD consults as it's either so obvious after 5 minutes that it's ADHD that any PCP should be able to identify it, or it's almost never ADHD. I have had 1 or 2 patients who likely have ADHD that I've picked up on, but I don't prescribe stimulants because I'm sending them back to their PCP who may or may not be willing to continue those meds.

In general, a "never stimulants" policy is pretty inappropriate if you're a psychiatrist. I think it's reasonable to say no stimulants at a first appointment or to try non-stimulants first while you're trying to pin down if it's actually ADHD or something else, but unless you're already in trouble with the DEA or state board then stimulants have to be a consideration for patients with legit ADHD.

I agree with Comp that neuropsych testing is generally a cop out and is usually totally unnecessary. Most docs I know that require neuropsych testing are either just lazy and don't want to prescribe stimulants or take the time to evaluate appropriately. OR they think it will somehow mitigate their liability by having someone else diagnose ADHD. It can be valid if you have concerns about some other underlying developmental disorder or want IQ testing (I've had more than a few low-IQ individuals come in because ADHD MUST be why they can't do hard jobs), but reflex neuropsych testing for every possible ADHD patient is just bad practice imo.

 

[psydocc]

How are you all going about treating ADHD and writing for stimulants in outpatient/private practice? In my clinic I have attendings who 1) never prescribe stimulants no matter what, 2) require neuropsych testing first, or 3) fine with starting (usually just DSM criteria, other psych conditions controlled, and no red flags). I have heard many private practice psychiatrists have a no benzo no stimulants policy. Wondering how all of you got about it considering my only experience so far is in the context of residency (PGY-3). Thanks!

Your experience of each attending doing their own thing is what is happening in private practice as well since there is no recognized gold standard for these adult ADHD evals. Even a diagnosis in childhood must be double checked to make sure it didn't originate haphazardly from a pediatric NP.

Anecdotally, I've noticed a lot of the tiktok self-referrals will ham up their "distractibility" by dramatically looking around the room side to side during the evaluation. That behavior magically stops the moment I tell them they might have a motor tic disorder instead of ADHD...

 

[romanticscience]

I’m seeing a surge in this in private practice. My usual process is SCID-CV after a developmental history. If suspect non-credible reporting, I employ some symptom validity measures and sometimes the TOMM.

I agree with splik, the rate of “hysterical” ADHD is immense. Unlike other functional cognitive disorders, testing really can’t rule it out. It frustrates me that the criteria are subjective but ALSO suppose to be cognitive in nature.

I highly recommend the following read:

Suhr, J., & Wei, C. (2017). Attention deficit/hyperactivity disorder as an illness identity: Implications for neuropsychological practice. In K. B. Boone (Ed.), Neuropsychological evaluation of somatoform and other functional somatic conditions: Assessment primer (pp. 251–273). Routledge/Taylor & Francis Group


Any tips for seeing patients who were “told” that they had ADHD by a psychiatrist relatively recently, started stimulants which “changed their life,” are stable and looking to continue bc old doctor left practice?

It’s hard enough telling patients who consult for it they don’t have it, let along challenging another providers reinforced expectancy.

 

[comp1]

I really like the idea of requiring substance abstinence before making any sort of ADD Dx. The amount of people chain smoking marijuana and complaining of their inability to concentrate is a lot.

 

[Atreides]

Requests for ADHD evaluation are, by far, the most common reason people request an appointment with me.

I'd go beyond saying that neuropsychological testing isn't needed. In most cases, it's worse than useless. If you read some of the reports that some private practice neuropsychologists churn out, you'd cringe. I've gotten so many patients who come to me with "neuropsychologist confirmed ADHD" and when I read the report, it's straight trash. Almost no clinical history obtained, just making the diagnosis based on some questionable neuropsych measures. Cynically, some neuropsychologists have found that they can charge top dollar to rubber stamp an ADHD diagnosis on a report that a PCP or midlevel will briefly skim.


There's no way around an ADHD diagnosis other than a full clinical interview. I've put together my own semi-structured interview based on the DIVA-5 and ACE plus, along with random tidbits I've picked up during fellowship and at various conferences (and psych social media like FB and SDN lol). It's constantly being updated but happy to share it with you if you DM me. I tell my patients at the outset (as in, when they request an appointment) that it's going to take multiple appointments to arrive at a diagnosis and that it may or may not be ADHD.

I know there're emerging debates about "adult onset ADHD" but those are above my pay grade. I stick with the DSM-5 and insist on evidence of childhood symptoms to make the diagnosis.

I do a CAT-A for every ADHD eval. It honestly rarely informs my decision-making beyond the clinical interview but I find it helpful to have some quantifiable data to support my clinical impression. For patients with elevated validity scores on the CAT-A or anything that even slightly raises a red or yellow flag about diversion and/or malingering, I do a TOMM. It's impressive how many med students with attention issues fail the TOMM so dramatically.

One of the things that helps is preparing a spiel for when you diagnose patients with NOT having ADHD. If they've got something like bipolar or OCD or PTSD, it's fairly easy to segue into that. With MDD and GAD, a bit harder but doable. The tricky part is people who don't really have a clear Axis I disorder. You have to validate that there's a disconnect between what they want their attention to be and what it seems to be. Then reframe it is as n adaptive response ("your brain is responding like it should to unrealistic demands/high stress/major life transitions/etc"). Pivot to things that will help them. Sleep hygiene, stress management, therapy for perfectionism, addressing relationship problems directly (can't tell you how many "ADHD evals" I've done that are one spouse demanding that their partner be evaluated for ADHD). Discuss something actionable so you can give them something rather than leave them feeling like they're leaving empty-handed.

Sometimes "ADHD" is ADHD. Sometimes it's bipolar disorder or PTSD. Sometimes it's medicalization of existential angst. Sometimes it's learned helplessness and just another manifestation of an externalized locus of control. If you can identify what's actually going on, the spiel is going to be that much more effective. For all the "you don't have ADHD" patients I see, I also give them a handout with some time management/task management/productivity tips. If everything else misses, figure that at least will help them with their day to day life.

 

[allantois]

Requests for ADHD evals is what has pushed me in the past 4 years towards growing a more psychotherapy focused practice. It was somewhat interesting at first but I just can’t stand having the same conversations anymore. I’m not at all sure that it is at all a disorder - I think our culture has created unrealistic demands for attention. They don’t even have adderall in the vast majority of places in the world and people still manage without it

 

[Ceke2002]

Thanks that's very helpful. I haven't heard of the DIVA-5, WURS, and BDEFS. ASRS and DSM criteria are what I've been using but I'll read up on the others.

Just my personal opinion, as someone with a diagnosis of ADHD but I would be more than a little suspicious of/not comfortable with any medical professional who based an ADHD diagnosis off of just the ASRS and DSM criteria. For me, again just speaking personally, that would raise immediate red flags that the healthcare professional I'm seeing is either a) a pill pusher who just wants to 'diagnose' patients as fast as possible, or b) someone who has no interest whatsoever in the legitimate diagnosis and care of ADHD patients and simply wants to get the patient out of their office as fast as possible, without just making it a straight up refusal. Not saying this is you, just that this approach would make me a tad wary.

From what I know/can remember, when I was first (re)diagnosed as an adult circa 1999 testing consisted of the ASRS, a structured clinical interview, most likely WURS-25 and CAARS, as well as a possible TOMM or similar (some of the questions in the clinical interview did seem designed to catch someone out if they weren't being entirely honest). I do think the aforementioned tests and scales are more than fair if a patient is genuinely seeking a diagnosis of ADHD; there's been far too much self diagnosis with the ASRS and DSM Criteria alone even before the whole social media ADHD bandwagon got rolling.

Having said all of that I do agree with what others, like Splik, have said in regards to NeuroPsych or Neurological evaluations in general, when it comes to diagnosis ADHD. For example after completing a structured interview and a series of tests administered over more than one session, it probably wasn't entirely necessary for me to then also undergo additional NeuroPsych testing and brain scans. I mean I would think if a combination of a structured interview, ASRS, WURS-25, CAARS and TOMM (potentially) isn't indicating that a diagnosis of ADHD is appropriate, then stick a fork in me, I think we're done.

(disclaimer: again just my personal opinion as a layperson, and ADHD diagnosee with first hand patient experience of the diagnostic process)

 

[PsyDr]

.....

I know there're emerging debates about "adult onset ADHD" but those are above my pay grade. I stick with the DSM-5 and insist on evidence of childhood symptoms to make the diagnosis.

...

I was approached by a group that wanted to start a "geriatric onset ADHD clinic".

 

[mistafab]

ASRS is the most damaging publication out of Harvard to the western hemisphere in the 21st century.

These absolutely ignorant academics telling everyone to self-diagnose ADHD and highlight all the correct answers.... Perfect timing for the hysteria of adult ADHD in the land of Tic Toc and low IQ algorithms.

I completely understand the anger towards ivory tower types with horrible "evidence-based" metrics like this. Publish trash, get insurance panels to require it for stimulant prescription... Yay for science, right? These wretched invertebrates in the north east towers thinking they are true scientists. What an absolute joke to the scientific method. These folks couldn't design a study to save their life.

Why don't we just make a bunch of screeners to utilize every addictive medication we prescribe? Adult anxiety disorder screener for benzos! Heck, what about a pain screener for opioids! Hurrah! I've got sad life disorder - the screener said so! Prescribe me some heroin, psilocybin, and ketamine! The self report said so! You're gatekeeping! Stop gaslighting me! I have ADHD, sad life, and pain - all on self report! Prescribe me cocaine!

 

[PsyDr]

@mistafab

1) Please allow me to share my favorite article from the inventor of the modern concept of residency:

(Halstead, 1885). Practical comments on the use and abuse of cocaine; suggested by its invariably successful employment in more than a thousand minor surgical operations NY Med J.; 42:294-295

With a title like that, it's no wonder.... Wright Jr, J. R. and N. S. Schachar (2020). "Necessity is the mother of invention: William Stewart Halsted’s addiction and its influence on the development of residency training in North America." Can J Surg 63(1): E13-e19.

2) You're aware that Nemeroff was in North Carolina, and moved to Texas where Andrew Wakefield lives, right? I don't think that's better than the Northeast.

 

[mistafab]

@mistafab

1) Please allow me to share my favorite article from the inventor of the modern concept of residency:

(Halstead, 1885). Practical comments on the use and abuse of cocaine; suggested by its invariably successful employment in more than a thousand minor surgical operations NY Med J.; 42:294-295

With a title like that, it's no wonder.... Wright Jr, J. R. and N. S. Schachar (2020). "Necessity is the mother of invention: William Stewart Halsted’s addiction and its influence on the development of residency training in North America." Can J Surg 63(1): E13-e19.

2) You're aware that Nemeroff was in North Carolina, and moved to Texas where Andrew Wakefield lives, right? I don't think that's better than the Northeast.

Love these classics.

Nemeroff is definitely a known entity... And known personality. Not a surprise he chose Austin as his nest in Texas.

 

[FatherPsychiatry]

@mistafab

1) Please allow me to share my favorite article from the inventor of the modern concept of residency:

(Halstead, 1885). Practical comments on the use and abuse of cocaine; suggested by its invariably successful employment in more than a thousand minor surgical operations NY Med J.; 42:294-295

With a title like that, it's no wonder.... Wright Jr, J. R. and N. S. Schachar (2020). "Necessity is the mother of invention: William Stewart Halsted’s addiction and its influence on the development of residency training in North America." Can J Surg 63(1): E13-e19.

2) You're aware that Nemeroff was in North Carolina, and moved to Texas where Andrew Wakefield lives, right? I don't think that's better than the Northeast.

Whoa, so Halstead, the inventor of residency, and Freud, the inventor of psychiatry, were both crackheads? (well cocaine but crackhead sounds better). Maybe they were self-medicating their ADHD?

 

[Merovinge]

Whoa, so Halstead, the inventor of residency, and Freud, the inventor of psychiatry, were both crackheads? (well cocaine but crackhead sounds better). Maybe they were self-medicating their ADHD?

I always bemoan missing the boat when it was reasonable to stay at your patient's vacation home and take lines together 🤣. It's somehow harder for me to imagine that then the pre-electricity era of human history.

 

[splik]

Whoa, so Halstead, the inventor of residency, and Freud, the inventor of psychiatry, were both crackheads? (well cocaine but crackhead sounds better). Maybe they were self-medicating their ADHD?

Not to get off topic but Freud was not the inventor of psychiatry (the term was coined by Johann Christian Reil) and Philippe Pinel is typical regarded as the father of psychiatry. Jung described Freud as "the neurologist who brought psychology to psychiatry." Freud was not a psychiatrist and had a strong contempt and disdain for psychiatry. While often portrayed as a coke fiend, it's not clear that he was addicted to it. He discovered the local anesthetic properties of cocaine, and self-experimented (in the name of science!) as was common in that era. Probably one of the issues of contemporary psychopharmacology is we don't try these things out ourselves anymore. Freud definitely did not have ADHD - he worked long hours seeing patients, and then wrote prolifically into the late hours. Most of his writings came long after he had stopped using cocaine regularly.

That said, in some fields, Adderall etc has become the new cocaine. In my day, med students used cocaine as did the finance bros to work long hours. Now its all prescription stimulants.

 

[zenmedic]

Thanks for all the responses. I can definitely see there’s a big hole in my ADHD screening process. Although I think my training was great the first two years of my residency, my third year clinic experience has mostly been churn and burn to maximize RVUs for the clinic/attendings. I’ve had to do a lot of self study this year and I’ll add these screening tools to the list.

And adderall is definitely the new cocaine. I knew guys in med school that would take bumps of crushed up IR in between their board exam breaks. Then do it again at the bar later that night. Crazy.

 

[splik]

ASRS is garbage. It's the "valid" screening tool I see used most often and also the one that I see completely miss the actual diagnosis the most by far. It's fine for a quick screen, but I absolutely would not diagnose just based on that.

I know people like to hate on it, but I do find it a helpful part of a comprehensive assessment. It's face valid, and so it can help identify if people are faking ADHD if they are just endorsing everything and that does not comport with what you see and other data sources. I've also seen a bunch of pts who actually don't report much on that who think they have ADHD so you can be fairly confident they don't have ADHD in that case. It can also help to focus the evaluation and get specific examples of how the reported symptoms affect them now and in childhood.

When these online pill mills use it as the only thing to assess ADHD then of course it is a major problem.

The full Barkley scale (BDEFS) is one you're probably not going to see many psychiatrists using, as it's not specific for ADHD but is also a longer form (something like 90 items) that is more time consuming. The only person I know that uses the scale is a cognitive neurologist (neuropsych in our world) but he uses it for TBI evals. You might see people using the BAARS-IV, but this is similar to the ASRS and basically just runs through the DSM criteria.

I see a lot of TBI so it's helpful there, but Barkley is an ADHD guy so the BDEFS was definitely meant for ADHD assessment and can help distinguish executive function deficits in ADHD from other causes. You have to pay for it so that's one reason few psychiatrists will use it.

I agree that neuropsych testing is not needed. Many neuropsychologists will bounce back such referrals.

In private practice, ADHD evals have become bread and butter for neuropsychologists. In my area, ADHD and autism are the #1 reasons for neuropsych evals in private practice. In academic settings or the VA, they might bounce back referrals but this is how neuropsychologists earn their keep (aside from doing forensic IMEs etc) in PP.

I do think neuropsych evaluations can be helpful in some cases. It can be helpful to assess for other learning difficulties and have a measure of intelligence can also be helpful. Some people struggle because they don't have the requisite intelligence for their level of study etc. So, while testing isn't necessary to dx ADHD, it can be helpful for assessing intelligence and learning difficulties. Some psychiatrists prefer to have a psychological assessment (that for some reason psychiatrists call neuropsych because most psychiatrists don't seem to know the difference) because the psychologists spend more time doing the assessments.

The one area where neuropsychological evals are necessary are for accommodations for standardized tests - they want to see the objective data about attention, processing speed, executive function in granting accommodations for the Bar exam, USMLE, SATs etc Also pilots with ADHD have to have neuropsychological eval.

If suspect, I employ some symptom validity measures and sometimes the TOMM.

It's a bit concerning people are using the TOMM in this context. Even the manual cautions against doing so. The TOMM is a performance validity measure so it doesn't make much sense to be using it if you're not doing any neuropsych testing. Second, one PVT failure is not uncommon and does not necessarily indicate feigning/malingering. Third, it's not very sensitive to malingered ADHD. Only if someone thinks they should be impaired on it will they might be, but if they don't think the test has anything to do with ADHD sx they will do well even if malingering. If someone scores less than chance, you can be strongly convinced something doesn't add up but you have to put it all in context. I would think something like the B-test, along with embedded validity measures in the CPT might be more appropriate to evaluated feigned ADHD. Additionally, even if someone is feigning and fails the TOMM, they can still have ADHD, so a failure does not exclude it. Finally, it's not that hard to get an ADHD dx and stims. So if someone is paying for a thoughtful evaluation from someone who doesn't dish it out, I would think a bit more deeply about what is going on. Hysterical patients may also have PVT failures which do not represent outright feigning or malingering.

 

[Merovinge]

Not to get off topic but Freud was not the inventor of psychiatry (the term was coined by Johann Christian Reil) and Philippe Pinel is typical regarded as the father of psychiatry. Jung described Freud as "the neurologist who brought psychology to psychiatry." Freud was not a psychiatrist and had a strong contempt and disdain for psychiatry. While often portrayed as a coke fiend, it's not clear that he was addicted to it. He discovered the local anesthetic properties of cocaine, and self-experimented (in the name of science!) as was common in that era. Probably one of the issues of contemporary psychopharmacology is we don't try these things out ourselves anymore. Freud definitely did not have ADHD - he worked long hours seeing patients, and then wrote prolifically into the late hours. Most of his writings came long after he had stopped using cocaine regularly.

That said, in some fields, Adderall etc has become the new cocaine. In my day, med students used cocaine as did the finance bros to work long hours. Now its all prescription stimulants.

Can you tell me more if all the stories about Freud using cocaine with his patients is exaggerated/made up? I had heard that from a number of attendings in training, but he is such a polarizing figure it's hard to tell bias from historical fact.

 

[comp1]

We can definitely discuss the best test, but the TOMM, while not ideal, isn't exactly inappropriate for this use at all and I wish neuropsych in general had much more of a malingering focus if there's even a vague possibility for secondary gain. I think that would justify their use a great deal more than what currently is used. We need something like the MENT or SIRS normed for ADD. Discriminating among ADHD alone, ADHD with a comorbid psychological disorder, and feigned ADHD in a college sample - PubMed

 

[splik]

We can definitely discuss the best test, but the TOMM, while not ideal, isn't exactly inappropriate for this use at all. Discriminating among ADHD alone, ADHD with a comorbid psychological disorder, and feigned ADHD in a college sample - PubMed

The issue is using it as a standalone measure. PVTs are used to determine the validity of performance on neuropsychological tests. If you aren't doing any neuropsychological tests then it raises some eyebrows about using it. Similarly, using it as the sole PVT is generally considered problematic because you will have false positives for feigning depending on the cut-off.

 

[splik]

Can you tell me more if all the stories about Freud using cocaine with his patients is exaggerated/made up? I had heard that from a number of attendings in training, but he is such a polarizing figure it's hard to tell bias from historical fact.

Largely made up. He did use cocaine early on, and prescribed it. But this was largely before the advent of psychoanalysis. He wasn't coked up doing analysis. We know he recommended cocaine to a friend of his who was an opium addict, with disastrous consequences which caused him to largely forsake cocaine. That was in the 1880s - early in his career.

 

[PsyDr]

Largely made up. He did use cocaine early on, and prescribed it. But this was largely before the advent of psychoanalysis. He wasn't coked up doing analysis. We know he recommended cocaine to a friend of his who was an opium addict, with disastrous consequences which caused him to largely forsake cocaine. That was in the 1880s - early in his career.

Freud said he didn’t “put aside the cocaine brush” until 1896.

 

[splik]

Freud said he didn’t “put aside the cocaine brush” until 1896.

Some people have claimed he stopped in 1896, which was when his father died, but historically, psychoanalysts (including Freud's biographer Ernest Jones) claimed he stopped using in the 1880s, about 10 years before the publication of Studies in Hysteria. In his letters to Wilhelm Fleiss he wrote "the cocaine brush has been completely put aside" in 1896. But it's not clear when he stopped (or whether he continued occasional use thereafter). In 1895 he had written to Fleiss that "I need a lot of cocaine" to manage his nasal pain after a long period of abstinence.

Regardless, 1896 was very early in psychoanalysis, before the id, ego, and superego had been described, before the Oedipus complex, before his self-analysis, and right around the time he was developing dream interpretation.

 

[brosa]

Can you tell me more if all the stories about Freud using cocaine with his patients is exaggerated/made up? I had heard that from a number of attendings in training, but he is such a polarizing figure it's hard to tell bias from historical fact.

Just a side note that Freud is very respected in a lot of countries in the World. Almost all my attendings in the US had little to no respect to him without knowing anything about it. I have also seen med students disdain Freud, "oh he wanted to have sex with his mother, right? Crazy guy!". Don't really know if it was just here or if people are ignorant about Freud in other places in the US too.

In other countries, he is mostly seen as the father of psychoanalysis, who heavily influenced the next figures like Melanie Klein, his own daughter, and many others that came later.

 

[mistafab]

Just a side note that Freud is very respected in a lot of countries in the World. Almost all my attendings in the US had little to no respect to him without knowing anything about it. I have also seen med students disdain Freud, "oh he wanted to have sex with his mother, right? Crazy guy!". Don't really know if it was just here or if people are ignorant about Freud in other places in the US too.

In other countries, he is mostly seen as the father of psychoanalysis, who heavily influenced the next figures like Melanie Klein, his own daughter, and many others that came later.

I think a part of this zeitgeist in the US against Freud relates to how severely dominated the US psychiatric academic centers were by psychoanalytic leanings. It was a major shakeup that occurred in the US when "biological psychiatry" pushed against the psychoanalysts with a successful rebellion and eventual coup of major academic centers/thinkers/trainees. This then brought the US front and center into the thinking that has since shaped psychiatric trainees, psychological thinkers (DSM-based/"evidence-based"), and eventual public discourse across the globe at a time when the science in mental health exploded and the NIMH/NIH funding was dominated by "imaging-or-bust" thinking.

A very US-centric biological psychiatry model has been now exported via the DSM iterative versions and the billions of dollars poured into the NIH/NIMH research coffers as well as pharmaceutical industry sponsored research which relies on biological solutions for biological problems (same for the Hospital system lobby, a powerful/growing force) and PE-driven ideas of RVU, productivity, etc. This "perfect storm" as it were benefits greatly from devaluing the contributions of analysis and Freud's work which is simply a caricature for a version of psychiatry where modern proclivities and financial incentives are set up to reward biology-oriented thinking - not deep thinking.

 

[splik]

Just a side note that Freud is very respected in a lot of countries in the World. Almost all my attendings in the US had little to no respect to him without knowing anything about it. I have also seen med students disdain Freud, "oh he wanted to have sex with his mother, right? Crazy guy!". Don't really know if it was just here or if people are ignorant about Freud in other places in the US too.

In other countries, he is mostly seen as the father of psychoanalysis, who heavily influenced the next figures like Melanie Klein, his own daughter, and many others that came later.

Freud has a complicated legacy for sure and of course Americans would be uncomfortable with his focus on sexuality. However, there is probably no other country that has been more shaped by Freudian ideas than the US. It just happens that his ideas had most influence far beyond the consulting room and couch. Freudian ideas influence ideas of individuality, advertising, the focus on the self, the human potential movement and all the therapies of the mid-20th century and politics. It was in part Freudian ideas that got Reagan elected, led to a political realignment and birthed the New Democrats like Clinton.

There was always something subversive about psychoanalytic ideas and that is something that was embraced in Europe and Latin America. But it was totally stripped from American Psychoanalysis which until as recently as the early 1990s was heavily dominated by MDs to the near exclusion of others - over Freud’s expressed wishes.

 

[cara susanna]

Requests for ADHD evaluation are, by far, the most common reason people request an appointment with me.

I'd go beyond saying that neuropsychological testing isn't needed. In most cases, it's worse than useless. If you read some of the reports that some private practice neuropsychologists churn out, you'd cringe. I've gotten so many patients who come to me with "neuropsychologist confirmed ADHD" and when I read the report, it's straight trash. Almost no clinical history obtained, just making the diagnosis based on some questionable neuropsych measures. Cynically, some neuropsychologists have found that they can charge top dollar to rubber stamp an ADHD diagnosis on a report that a PCP or midlevel will briefly skim.


There's no way around an ADHD diagnosis other than a full clinical interview. I've put together my own semi-structured interview based on the DIVA-5 and ACE plus, along with random tidbits I've picked up during fellowship and at various conferences (and psych social media like FB and SDN lol). It's constantly being updated but happy to share it with you if you DM me. I tell my patients at the outset (as in, when they request an appointment) that it's going to take multiple appointments to arrive at a diagnosis and that it may or may not be ADHD.

I know there're emerging debates about "adult onset ADHD" but those are above my pay grade. I stick with the DSM-5 and insist on evidence of childhood symptoms to make the diagnosis.

I do a CAT-A for every ADHD eval. It honestly rarely informs my decision-making beyond the clinical interview but I find it helpful to have some quantifiable data to support my clinical impression. For patients with elevated validity scores on the CAT-A or anything that even slightly raises a red or yellow flag about diversion and/or malingering, I do a TOMM. It's impressive how many med students with attention issues fail the TOMM so dramatically.

One of the things that helps is preparing a spiel for when you diagnose patients with NOT having ADHD. If they've got something like bipolar or OCD or PTSD, it's fairly easy to segue into that. With MDD and GAD, a bit harder but doable. The tricky part is people who don't really have a clear Axis I disorder. You have to validate that there's a disconnect between what they want their attention to be and what it seems to be. Then reframe it is as n adaptive response ("your brain is responding like it should to unrealistic demands/high stress/major life transitions/etc"). Pivot to things that will help them. Sleep hygiene, stress management, therapy for perfectionism, addressing relationship problems directly (can't tell you how many "ADHD evals" I've done that are one spouse demanding that their partner be evaluated for ADHD). Discuss something actionable so you can give them something rather than leave them feeling like they're leaving empty-handed.

Sometimes "ADHD" is ADHD. Sometimes it's bipolar disorder or PTSD. Sometimes it's medicalization of existential angst. Sometimes it's learned helplessness and just another manifestation of an externalized locus of control. If you can identify what's actually going on, the spiel is going to be that much more effective. For all the "you don't have ADHD" patients I see, I also give them a handout with some time management/task management/productivity tips. If everything else misses, figure that at least will help them with their day to day life.

Yup, I've literally seen ADHD testing reports where they didn't even go through DSM-5 criteria and just gave the results of cognitive measures.

I've also seen some neuropsychologists diagnose "adult onset ADHD" which is not a thing. All of the reputable neuropsychologists that I know won't even accept ADHD referrals unless there is some cognitive rule-out required, or the patient is in school and specifically wants strengths/weaknesses.

 

[Stagg737]

I know people like to hate on it, but I do find it a helpful part of a comprehensive assessment. It's face valid, and so it can help identify if people are faking ADHD if they are just endorsing everything and that does not comport with what you see and other data sources. I've also seen a bunch of pts who actually don't report much on that who think they have ADHD so you can be fairly confident they don't have ADHD in that case. It can also help to focus the evaluation and get specific examples of how the reported symptoms affect them now and in childhood.

When these online pill mills use it as the only thing to assess ADHD then of course it is a major problem.

If it's only one part of a comprehensive assessment then I have no problem with it, but 99% of the time it's being given by a PCP office, pill mill, or just a quiz a patient took online as "proof" the patient has ADHD. It's basically just the DSM criteria with a likert scale, so I don't really find it all that helpful if we're already doing a more comprehensive eval anyway.

I see a lot of TBI so it's helpful there, but Barkley is an ADHD guy so the BDEFS was definitely meant for ADHD assessment and can help distinguish executive function deficits in ADHD from other causes. You have to pay for it so that's one reason few psychiatrists will use it.

Sure, but it's not a specific tool for ADHD and there are plenty of other scales and tools out there which are designed specifically for ADHD. I'm sure this is part why the only guy I know who uses it is a cognitive neurologist, because he's looking for a more global assessment of EF than just ADHD. And the whole paying to use it part.

Some psychiatrists prefer to have a psychological assessment (that for some reason psychiatrists call neuropsych because most psychiatrists don't seem to know the difference) because the psychologists spend more time doing the assessments.

My father was a neuropsychologist and one of my mentors in residency was a wonderful psychometrician and it kills me a little inside whenever a psychiatrist I meet doesn't know the difference between psychological testing and neuropsych testing. Neuropsych testing absolutely can be helpful as you described, but most patients coming in asking specifically for ADHD testing don't care about other neurodevelopmental problems or having lower IQ in any area, they want their stims to focus gooder.

 

[brosa]

Yup, I've literally seen ADHD testing reports where they didn't even go through DSM-5 criteria and just gave the results of cognitive measures.

I've also seen some neuropsychologists diagnose "adult onset ADHD" which is not a thing. All of the reputable neuropsychologists that I know won't even accept ADHD referrals unless there is some cognitive rule-out required, or the patient is in school and specifically wants strengths/weaknesses.

Hot take, but I do believe this exists. Yes, it is not a DSM diagnosis, but I have had quite a few patients that fully fit ADHD criteria without childhood history. The thing is, a lot of these patients are not necessarily looking for stims, but just want help. People who seek stims will often create stories about childhood. I wonder if this could be related to COVID.

If I am not mistaken, there is recent research suggesting that a significant chunk of adult ADHD is indeed adult onset.

 

[oliversacks4thewin]

Hot take, but I do believe this exists. Yes, it is not a DSM diagnosis, but I have had quite a few patients that fully fit ADHD criteria without childhood history. The thing is, a lot of these patients are not necessarily looking for stims, but just want help. People who seek stims will often create stories about childhood. I wonder if this could be related to COVID.

If I am not mistaken, there is recent research suggesting that a significant chunk of adult ADHD is indeed adult onset.

I started to write a few things, stopped, rewrote, stopped, rewrote, and then realized that Dr. Barkley, himself may just do a better job of talking about this lol:



It's dated, but I feel like he discusses the matter with a candor that respects the emerging evidence base while also acknowledging the limits.

 

[R. Matey]

It's dated, but I feel like he discusses the matter with a candor that respects the emerging evidence base while also acknowledging the limits.

So this is where I think Barkley goes off the rails. Studies that use clinician interviews, not just self-report, find that very few cases of ADHD cases have an onset past 12 years old, typically don't meet impairment criterion, and are often explainable by comorbidities. Furthermore, the argument that "self-report is unreliable" assumes that we have a more reliable method to assess ADHD than observation and reporting, which we do not. Furthermore, many psychiatric conditions are diagnosed on retrospective reporting. At what point do people's estimation about the frequency, duration, and onset of symptoms become fuzzy? Last I checked, we're not really holding the last three weeks of our lives in working memory. So this criticism could be leveled at basically any measure, including BAARS self- and other-childhood symptom form (which are already iffy psychometrically).

I have a lot of respect for Barkley's EF work, but I think he's not correct on this point. And it's non-trivial, patients, citing Barkley as evidence, have argued that I should not consider the age cut off for their adult onset symptoms. I reiterate that, as a clinician, my diagnoses are based on the DSM-5-TR.

Papers for the interested:

Little evidence for late-onset ADHD in a longitudinal sample of women - PubMed

Although 19.5% of women from our subsample without childhood ADHD met symptom criteria for ADHD during adolescence/adulthood, only one showed the needed combination of impairment and cross-situational symptoms without significant co-occurring mental health problems. It is possible that...

pubmed.ncbi.nlm.nih.gov

https://psychiatryonline.org/doi/10.1176/appi.ajp.2017.17030298

Recent paper showing that adults often report adult-onset ADHD symptoms in the general population: https://www.sciencedirect.com/science/article/pii/S0213616325000485

 

[psydocc]

It's dated, but I feel like he discusses the matter with a candor that respects the emerging evidence base while also acknowledging the limits.

I like Barkley, but it's clear he is an academic at heart who draws from his research experience of the 1990s and not today's clinical environment. It is painfully obvious in clinical practice that most adult ADHD eval requests end up being cannabis, anxiety, and/or insomnia issues.

 

[brosa]

I started to write a few things, stopped, rewrote, stopped, rewrote, and then realized that Dr. Barkley, himself may just do a better job of talking about this lol:



It's dated, but I feel like he discusses the matter with a candor that respects the emerging evidence base while also acknowledging the limits.

I watched the interview and I agree a lot with his view. So ultimately what I view as adult-onset is just a miss match between what I see clinically vs what the DSM tells me. His thoughts about ADHD match what I see in the office daily much more than the DSM criteria.

 

[oliversacks4thewin]

Appreciate all of the responses. I actually am inclined to agree with @R. Matey but wanted to include Dr. Barkley's more up to date discussion:


I will confess, my work is predominately in the pediatric sector, so I can certainly be biased in this as well. I felt like Dr. Barkley was suggesting that while he also believes the condition to be predominately neurodevelopmental, save for some of the associated ABI cases, including the complexity of substance use, he referenced, it is hard to determine specific observations of symptoms at certain ages. I felt like he was making a case for more undiagnosed cases hitting critical threshold as environmental demands rise... but maybe I am the one misinterpreting. I'll say the heritability evidence is compelling (typically estimated at 76%) but leaves room for additional outliers and further research.

I am always thinking of the potential epigenetic pieces (articles cited below) that may shed further light into these questions, regarding the neurodevelopmental vs "late onset" discussions:

The Role of Epigenetics in the Pathogenesis and Potential Treatment of Attention Deficit Hyperactivity Disorder - PubMed

There is increasing evidence that dysregulated epigenetic mechanisms of gene expression are involved in the pathogenesis of attention deficit hyperactivity disorder (ADHD). This review presents a comprehensive summary of the current state of research on the role of epigenetics in the...

pubmed.ncbi.nlm.nih.gov

Epigenetics and ADHD - PubMed

There is robust evidence of genetic susceptibility to Attention-Deficit Hyperactivity Disorder (ADHD); however, there still remains significant variability that is not attributable to genetic factors. The emerging field of epigenetics is beginning to reveal how genotypic expression can be...

pubmed.ncbi.nlm.nih.gov

As always, love the discussions! We treat complex conditions, it requires a number of critical perspectives.

 

[brosa]

So this is where I think Barkley goes off the rails. Studies that use clinician interviews, not just self-report, find that very few cases of ADHD cases have an onset past 12 years old, typically don't meet impairment criterion, and are often explainable by comorbidities. Furthermore, the argument that "self-report is unreliable" assumes that we have a more reliable method to assess ADHD than observation and reporting, which we do not. Furthermore, many psychiatric conditions are diagnosed on retrospective reporting. At what point do people's estimation about the frequency, duration, and onset of symptoms become fuzzy? Last I checked, we're not really holding the last three weeks of our lives in working memory. So this criticism could be leveled at basically any measure, including BAARS self- and other-childhood symptom form (which are already iffy psychometrically).

I have a lot of respect for Barkley's EF work, but I think he's not correct on this point. And it's non-trivial, patients, citing Barkley as evidence, have argued that I should not consider the age cut off for their adult onset symptoms. I reiterate that, as a clinician, my diagnoses are based on the DSM-5-TR.

Papers for the interested:

Little evidence for late-onset ADHD in a longitudinal sample of women - PubMed

Although 19.5% of women from our subsample without childhood ADHD met symptom criteria for ADHD during adolescence/adulthood, only one showed the needed combination of impairment and cross-situational symptoms without significant co-occurring mental health problems. It is possible that...

pubmed.ncbi.nlm.nih.gov

https://psychiatryonline.org/doi/10.1176/appi.ajp.2017.17030298

Recent paper showing that adults often report adult-onset ADHD symptoms in the general population: https://www.sciencedirect.com/science/article/pii/S0213616325000485

To be fair I also give very little value to retrospective unspecific manic symptoms. I always screen for bipolar disorder, and I would say a good amount of my patients say they have those symptoms, but then it becomes clear they are not talking about a manic episodes when asked further.

 

[Candidate2017]

How are you all going about treating ADHD and writing for stimulants in outpatient/private practice?

PP standard of care is give the people what they want until something bad happens. This is more reality than joke.

 

[R. Matey]

I will confess, my work is predominately in the pediatric sector, so I can certainly be biased in this as well. I felt like Dr. Barkley was suggesting that while he also believes the condition to be predominately neurodevelopmental, save for some of the associated ABI cases, including the complexity of substance use, he referenced, it is hard to determine specific observations of symptoms at certain ages. I felt like he was making a case for more undiagnosed cases hitting critical threshold as environmental demands rise... but maybe I am the one misinterpreting. I'll say the heritability evidence is compelling (typically estimated at 76%) but leaves room for additional outliers and further research.

When conceptualized as a latent trait (which itself is a whole other discussion), I could see this where subacute or subthreshold symptoms wax above the clinical threshold under environmental demands. However, ADHD does not necessarily require high environmental demands for phenotypical expression, and it's debatable about what types of demands function as valid exposure.

Understanding Environmental Exposures and ADHD: a Pathway Forward - PubMed

This commentary addresses a series of articles in Prevention Science about environmental causes of attention deficit hyperactivity disorder (ADHD). It provides an overview of their key findings and places them in a broader context to facilitate their interpretation. Each of the articles included...

pubmed.ncbi.nlm.nih.gov

 

[oliversacks4thewin]

When conceptualized as a latent trait (which itself is a whole other discussion), I could see this where subacute or subthreshold symptoms wax above the clinical threshold under environmental demands. However, ADHD does not necessarily require high environmental demands for phenotypical expression, and it's debatable about what types of demands function as valid exposure.

Understanding Environmental Exposures and ADHD: a Pathway Forward - PubMed

This commentary addresses a series of articles in Prevention Science about environmental causes of attention deficit hyperactivity disorder (ADHD). It provides an overview of their key findings and places them in a broader context to facilitate their interpretation. Each of the articles included...

pubmed.ncbi.nlm.nih.gov

Thank you so much for the exchange. I'll confess, I read and reread the article you provided, and I am struggling to understand how it is germane to the current discussion topic. I always enjoy a good article (and this one is quite fascinating in discussing how environmental toxins, APGAR scores, and prenatal exposures can impact ADHD development), so I am hoping you can steer me to the point in the article that I should be focusing towards, as I must be missing it.

I understand the point you are making towards phenotypical presentation, but I also think there is a reason that we typically do not feel confident in assessment, until environmental demands are present. It's part of the difficulty in parsing out normal development in a five year old from inherent signs of ADHD and I think consistent with the DSM-5-TR in identifying two distinct environments, where dysfunction is seen. ADHD is a diagnosis typically made with school-aged children (although, there are exceptions, and, boy howdy, have I seen them!), as it shows how the deficits are reflected when demands like the structures of academics are present. Does that make sense too... or am I just rambling? Lol

 

[Stagg737]

Thank you so much for the exchange. I'll confess, I read and reread the article you provided, and I am struggling to understand how it is germane to the current discussion topic. I always enjoy a good article (and this one is quite fascinating in discussing how environmental toxins, APGAR scores, and prenatal exposures can impact ADHD development), so I am hoping you can steer me to the point in the article that I should be focusing towards, as I must be missing it.

I understand the point you are making towards phenotypical presentation, but I also think there is a reason that we typically do not feel confident in assessment, until environmental demands are present. It's part of the difficulty in parsing out normal development in a five year old from inherent signs of ADHD and I think consistent with the DSM-5-TR in identifying two distinct environments, where dysfunction is seen. ADHD is a diagnosis typically made with school-aged children (although, there are exceptions, and, boy howdy, have I seen them!), as it shows how the deficits are reflected when demands like the structures of academics are present. Does that make sense too... or am I just rambling? Lol

I didn’t read the article, but I believe the point is just that ADHD symptoms/phenotypes/traits or whatever term you want to use are likely going to be notable regardless of the demand of the environment and activities. It’s easiest to diagnose at school because for many it’s the first time a kid is instructed to perform basic specific tasks (stay in your chair, don’t interrupt the teacher, write these letters, etc) under observation of professionals who know what “normal” looks like.

Unless parents are somehow already trained or aware of what to look for with ADHD, like if an older sibling is treated, then they’re probably not going to think there are any issues until then unless there are severe hyperactive symptoms. Even then, they’ll likely miss it unless they’re very attentive or are trained in what to look for, ie CAP. Just think about how many times with childhood disorders you talk to parents and after telling them symptoms they say something like, “we just thought Timmy had lots of energy” or “That’s totally normal for a 6 year old”.

That’s part of the point of making sure symptoms are present in multiple environments. Not just to make sure symptom presentation is not due to specific environment, but to also see if symptoms are present in lower stress situations, even if it is to a lesser extent.

 

[R. Matey]

Thank you so much for the exchange. I'll confess, I read and reread the article you provided, and I am struggling to understand how it is germane to the current discussion topic. I always enjoy a good article (and this one is quite fascinating in discussing how environmental toxins, APGAR scores, and prenatal exposures can impact ADHD development), so I am hoping you can steer me to the point in the article that I should be focusing towards, as I must be missing it.

@Stagg737 basically nailed it. I'll only add the point of the paper was to show we do not even have good understanding of which environmental exposures are associated with ADHD onset, much less its maintenance and severity. Maggie Sibley put a paper a few years ago showing that ADHD was responsive to environmental demands in the MTA, but I wasn't very satisfied with the way it was measured (not to mention that variability in ADHD symptom reports do not account for measurement error). It's probably true that ADHD are respondent to stress, but like Stagg said, we would expect ADHD symptoms to be present in low stress environments.

 

[brosa]

But the whole point is that symptoms are not seen in low stress environments, not that they don't exist, isn't it? Little Jimmy getting A- on his Arts class will unlikely lead him to a psychiatrist office, even if he is doing a lot of things wrong, not paying attention, etc. Then he goes to college and realizes he can't just draw a stick guy and get a good grade.

The argument that adult adhd has always be present seems pretty possible for me.

 

[Stagg737]

But the whole point is that symptoms are not seen in low stress environments, not that they don't exist, isn't it? Little Jimmy getting A- on his Arts class will unlikely lead him to a psychiatrist office, even if he is doing a lot of things wrong, not paying attention, etc. Then he goes to college and realizes he can't just draw a stick guy and get a good grade.

The argument that adult adhd has always be present seems pretty possible for me.

Basically. A core nosological premise of ADHD is that it’s a pervasive neuro developmental disorder, so symptoms are always present in all or most settings. That does not mean that people with milder symptoms can’t or don’t hide it well or develop coping skills that are adequate until stressors are too great. I’d argue that asking about how people function when there aren’t stressors (or better yet, observing) is important to clarifying the diagnosis.

I could give you plenty of personal examples, but if a patient is telling you that they never dealt with symptoms until adulthood or that they never had problems until starting a certain level of school or job, that’s not ADHD.

 

[R. Matey]

I’d argue that asking about how people function when there aren’t stressors (or better yet, observing) is important to clarifying the diagnosis.

It's an important chicken-and-egg because EF difficulties often occur in response to stress and anxiety, which are often confused with ADHD and seem to abate when stimulants are started. Differentiating from ADHD means that symptoms are present (though perhaps more a milder form) in multiple settings independent of environmental demands. In the college example above that @brosa is positing, we would need to be certain that stress, adjustment concerns, or general academic problems do not fully explain inattentive symptoms. One way to do that would be to interrogate a developmental history and look for impairment outside the academic domain.

 

[PsyDr]

But the whole point is that symptoms are not seen in low stress environments, not that they don't exist, isn't it? Little Jimmy getting A- on his Arts class will unlikely lead him to a psychiatrist office, even if he is doing a lot of things wrong, not paying attention, etc. Then he goes to college and realizes he can't just draw a stick guy and get a good grade.

The argument that adult adhd has always be present seems pretty possible for me.

Now add FSIQ as an additional factor into your argument.

Jimmy is relatively bright. Gets A grades in general education classes in high school in a rural BS state (e.g., Mississippi). Goes to Community College, gets A-Bs in his 101 general classes. Goes to the Satellite Campus of Rural State University. Gets Bs-Cs in his 105 classes for his communications major classes, gets Cs-Ds in his advanced communication classes, and gets Ds-Fs when he attempts advanced science classes. Is it ADHD in a higher stress environment that is limiting his performance, or is Jimmy's IQ reached the limit of what it can do?

Sally is very bright. Gets As in her advanced classes in an affluent, urban university town. Gets a near perfect score on her SATs, goes to an Ivy, where she gets straight As in all subjects with ease, and majors in some weirdo branch of math. In the breaks, she tours in a signed, band. She goes on to get a PhD from Oxford or Cambridge, goes into finance, and marries someone awesome. Is this ADHD that has never been in a high stress environment, or is Sally just cruising through life with the FSIQ equivalent of an F1 race car?

There is an issue of ability. How many providers are telling patients that they are performing exactly to their abilities? I've never seen it.

 

[Merovinge]

Now add FSIQ as an additional factor into your argument.

Jimmy is relatively bright. Gets A grades in general education classes in high school in a rural BS state (e.g., Mississippi). Goes to Community College, gets A-Bs in his 101 general classes. Goes to the Satellite Campus of Rural State University. Gets Bs-Cs in his 105 classes for his communications major classes, gets Cs-Ds in his advanced communication classes, and gets Ds-Fs when he attempts advanced science classes. Is it ADHD in a higher stress environment that is limiting his performance, or is Jimmy's IQ reached the limit of what it can do?

Sally is very bright. Gets As in her advanced classes in an affluent, urban university town. Gets a near perfect score on her SATs, goes to an Ivy, where she gets straight As in all subjects with ease, and majors in some weirdo branch of math. In the breaks, she tours in a signed, band. She goes on to get a PhD from Oxford or Cambridge, goes into finance, and marries someone awesome. Is this ADHD that has never been in a high stress environment, or is Sally just cruising through life with the FSIQ equivalent of an F1 race car?

There is an issue of ability. How many providers are telling patients that they are performing exactly to their abilities? I've never seen it.

This is why I like getting psychologic testing in kids. I find the FSIQ alone is very helpful and there are certainly additional neuropsychologic tests that add to the understanding of the overall picture. Not to say I haven't/can't/won't diagnosis ADHD without testing (I did it all the time in outpatient CAP), but psychologic testing is absolutely helpful for understanding the whole picture.