What to do when you see a report that blatantly misuses measures, misdiagnoses?

[singasongofjoy]

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Tl;dr: What do you do when you run across a report from another provider that is AWFUL , misused measures, misdiagnosis, bad bad bad?

Long version (includes some venting): I'm feeling a bit perseverative on this terribly written report I received for a client I saw earlier this week.

This kid came to me with an autism diagnosis from a community provider (master's level; we were seeing htem for insurance purposes- diagnosis requires doctoral/MD for coverage). The assessment was done 6 months ago.

The report from the community provider is AWFUL. The report stated a clinical interview was conducted but the writeup was literally 6 sentences. The writeups for the measures administered and computer-scored (Vineland, IQ screening, BASC) were copy-paste from the scoring output, and didn't always say which measure was completed by whom and was generally super confusing even for me, but ok, I'll give benefit of the doubt and assume at least the scores are probably correct even if I don't know which was done by the teacher and which by the parent.

What I can't get over is that 1) the summary, which gives diagnoses of autism and ADHD. There is no descriptive explanation of why ADHD; I assume it's based on scores on the BASC. and 2) what IS DRIVING ME NUTS: the autism diagnosis is based (it seems) entirely on the fact that she gave copies of the CARS to the teacher (who reported minimal to no symptoms range, though did endorse social isolation, lack of eye contact, and lack of communication) and the mom (who reported super high scores on everything). So the report surmises the extra structure of school must essentially cover up the other obviously autism symtoms mom reports.

For those of you who do not know, the CARS rating scale is supposed to be completed BY THE CLINICIAN, largely based on direct observation, especially for the ST (standard, not high-functioning version). WTF. This kid is one of the most anxious kids I have ever seen and has trauma history and really disorganized family (though better the past several months). FWIW, I diagnosed the kid with (really bad) speech disorder, anxiety, and other trauma/stress related (not my area of expertise or focus of assessment, but the kid has been separated from his mother multiple times and put in foster care and had no idea/understanding of why and makes comments like "mommy why did you give me away." Did that not come up in the previous eval? Because that behavior was definitely happening then).

I just wonder how many other kids are out in this community with autism diagnoses so poorly given by this provider. There aren't many providers in that area of the state. I looked this provider up and she's one of those who lists specialties in 15 types of therapy, 40 different issues/conditions, and every age range. It's a private practice; my assumption is they're probably trying to cram as many in as possible leading to ****ty work and working outside of expertise. Plus it's a rural area without many providers so I am sure demand is high.

So now that I've vented some, here's my question: with something this poorly done, like the obvious misuse of a measure, would you reach out to the clinician and let them know that the measure is meant to be administered differently? I don't know any tactful way to do that, but damn. The entire assessment is just SO BAD. Even the recommendations suck. DO you do anything in these cases? IF so, what?

 

[WisNeuro]

Recently, I talk to the referring neurologist and let them know that they are referring to someone who has no idea what they are doing, with some detailed explanations. It's how I filled my clinic up when I got to my current job. You'll see these reports quite often as there are plenty of psychologists who later decided they wanted to do assessment and never received the correct training, or just diploma mill hacks who had poor training in graduate school and couldn't get good internships/postdocs. I don't bother with talking to the crappy clinician, they are unlikely to care about their incompetence. If what they are doing is harming a patient in some way, a call to the board is justified.

 

[erg923]

Call provider---" I am working with so and so and have some questions about your assessment with him/her. Would you be willing to discuss this with me?" Repeat many times? Unless you are getting paid for this, Its likely to get old fast.

 

[PsyDr]

1) Sometimes people do bad things for decent reasons. I've seen ASD diagnoses which are borderline at best, but when I've reached out there are things like services which are available for such a diagnosis but not a related diagnosis. Not ideal, but I can see how it was made.

2) I've also seen pure incompetence. And reaching out either ignites a narcissistic reaction, or nothing at all.

3) I've also seen people who are competent that are willing shills.



@WisNeuro

Ever seen a diagnosis of Disorder of Written Expression because a truculent teenager wrote, "F off" on a writing subtest, which got a score of zero? Cause I have, and it was done by someone in leadership.

 

[singasongofjoy]

Recently, I talk to the referring neurologist and let them know that they are referring to someone who has no idea what they are doing, with some detailed explanations. It's how I filled my clinic up when I got to my current job. You'll see these reports quite often as there are plenty of psychologists who later decided they wanted to do assessment and never received the correct training, or just diploma mill hacks who had poor training in graduate school and couldn't get good internships/postdocs. I don't bother with talking to the crappy clinician, they are unlikely to care about their incompetence. If what they are doing is harming a patient in some way, a call to the board is justified.

Contacting the referring provider is a brilliant idea. Thanks for the suggestion.

 

[singasongofjoy]

Call provider---" I am working with so and so and have some questions about your assessment with him/her. Would you be willing to discuss this with me?" Repeat many times? Unless you are getting paid for this, Its likely to get old fast.

Actually did this a few years ago in a case where it seemed like it was a generally competent provider who just missed getting some info from folks other than stepmom (who had a real agenda) and it turned into a really fruitful conversation. Forgot about that until now. Certainly wouldn't expect that to be the norm though.

 

[WisNeuro]

@WisNeuro

Ever seen a diagnosis of Disorder of Written Expression because a truculent teenager wrote, "F off" on a writing subtest, which got a score of zero? Cause I have, and it was done by someone in leadership.

Haven't seen that yet. Did recently see amfake neuropsych grad dismiss stark visuospatial and EF deficits as anxiety in a case. Periods of confusion, progressive balance problems, and REM behavior disorder are all present. In no surprise, steady decline over the past 18 months.

 

[PsyDr]

Haven't seen that yet. Did recently see amfake neuropsych grad dismiss stark visuospatial and EF deficits as anxiety in a case. Periods of confusion, progressive balance problems, and REM behavior disorder are all present. In no surprise, steady decline over the past 18 months.

Probably late late late late late onset schizophrenia. Hit em with the thorazine.

 

[ClinicalABA]

1) Sometimes people do bad things for decent reasons. I've seen ASD diagnoses which are borderline at best, but when I've reached out there are things like services which are available for such a diagnosis but not a related diagnosis. Not ideal, but I can see how it was made.

I see this with a local developmental pediatrician way too often. Also, in some states, an ASD dx from a masters level clinician will qualify a child for early intervention/birth to three services. In many cases, the clinician works directly for the EI provider. I have heard pressure from the treatment team along the lines of “I hope you diagnose someone soon- we’re running low on hours in my region.” Just adds a level of pressure towards a positive dx that can get in the way of objectivity. Especially the case if the diagnostician is also a treating clinician who is low on treatment hours. I have a personal policy of not doing treatment with any kiddos I diagnose.

 

[deleted343839]

I have a personal policy of not doing treatment with any kiddos I diagnose.

Could you say more about this? Obviously this would be the case if you prefer to focus on assessment or you do not have the skill/competence to treat certain conditions, but you seem to be suggesting that somehow this makes your diagnosis more "objective" and I'm struggling to understand that, particularly as assessment seems to be the more lucrative activity.

 

[ClinicalABA]

Could you say more about this? Obviously this would be the case if you prefer to focus on assessment or you do not have the skill/competence to treat certain conditions, but you seem to be suggesting that somehow this makes your diagnosis more "objective" and I'm struggling to understand that, particularly as assessment seems to be the more lucrative activity.

It's more about me trying to avoid any impression that I give a diagnosis just so I can benefit financially from doing the treatment. I certainly think it's possible to be objective in the diagnosis when also doing the treatment. It's not a typical psychologist diagnose/treat thing in my case, as treatment is done by differently credentialled/licensed clinicians (e.g., BCBAs). I just happen to have both credentials so could provide both services. While I try to be very conservative and by the book with my diagnoses, it gets really frustrating when I see a child who would benefit tremendously from ABA services, but can't access them because they don't meet criteria for ABA. I can see how diagnosticians would feel ok about making a diagnosis with those borderline cases, especially if they knew a small "dose" of therapy from themselves would make a huge difference. I have this policy so I am not putting myself in this position. I also no myself- I become attached to all these little kiddos during the assessment and would have a difficult time maintaining a reasonable treatment caseload (it's hard enough for me to maintain a reasonable assessment caseload).

It can get a little political with Specialty EI services (e.g., autism services for kiddos under 3). My agency mainly does home-based specialty EI (and post 3 insurance funded) ABA services. Many years ago, the owner/president of my company- through his involvement with "standard" (e.g. non-autism specific) EI noted that the lack of diagnostic services available to children in standard EI services was getting in the way of children getting what they needed. As a result, my company added diagnostic clinics to each regional treatment office in the state. As this was done to increase ALL children's access to ALL specialty EI providers (not just one's affiliated with our clinic). I just try to keep things as "clean" as possible, as well as keep my roles with each client and clear and separate as possible. Maybe it's overkill, but I'm afforded the luxury of being able to do so (my next available assessment appointment is in August) and thus I do so!

ETA- Assessment is more lucrative relative to hourly rates for just my services, but in the case of treatment, each hour of my BCBA supervision allows for many more hours of billable direct service by non-credentialled staff. Given the right ratios, it may be more "lucrative" to the agency to bill for all of the services that me doing lower rate services would allow. I still maintain a small treatment caseload to keep on top of my skills (I also teach graduate courses in ABA, so it's good to still have my hand in the game), as well as have a little variety in what type of work and settings (treatment is all home-based) I encounter.

 

[deleted343839]

While I try to be very conservative and by the book with my diagnoses, it gets really frustrating when I see a child who would benefit tremendously from ABA services, but can't access them because they don't meet criteria for ABA. I can see how diagnosticians would feel ok about making a diagnosis with those borderline cases, especially if they knew a small "dose" of therapy from themselves would make a huge difference. I have this policy so I am not putting myself in this position.

Very understandable, especially in an insurance-based revenue model where the potential to cross the line into fraud adds another layer of complication.

I just try to keep things as "clean" as possible, as well as keep my roles with each client and clear and separate as possible. Maybe it's overkill, but I'm afforded the luxury of being able to do so (my next available assessment appointment is in August) and thus I do so!

Makes sense. Thanks for the insight. This is interesting to me in part because I have previously been on the receiving end of this process as a consumer (ie, parent of a child requiring assessment). It has been eye opening.

 

[ClinicalABA]

Very understandable, especially in an insurance-based revenue model where the potential to cross the line into fraud adds another layer of complication.



Makes sense. Thanks for the insight. This is interesting to me in part because I have previously been on the receiving end of this process as a consumer (ie, parent of a child requiring assessment). It has been eye opening.

I very much appreciate your feedback from the multiple perspectives. Thank you.