Where to learn more about adult ADHD?

[reca]

I feel I had a very good residency training experience but I've been inundated with adult ADHD referrals since coming out of training. I've also recently finished reading ADHD Nation by Alan Schwarz and guess I'm having a bit of an existential question about the nature of ADHD.

I'm not looking for resources on how to treat ADHD, I'm very comfortable with my pharmacology knowledge in that regards. More wondering about resources talking about how to better diagnose ADHD, impairments to look for, etc. It seems my patients have spent hours going down the rabbit hole of ADHD social media and come bombarding me with questions about emotional dysregulation, RSD, hyperfocus, time blindness, etc. I'm not even sure where to begin to find out more about these from an actual evidence based standpoint. The literature searches I've done have done been helpful in this regards.

Thanks!

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[splik]

I like the DIVA-5 for a structured interviewing approach for adult ADHD. The CAT-A has 3 validity scales embedded in it.
I like Driven to Distraction by Ned Hallowell and John Ratey. Although it's for patients, and they oversell ADHD, it did give me a helpful way of thinking about my assessments of ADHD and its comorbidities.

If you want to keep up to date with all these terms like RSD, hyperfocus etc, you can have a look at Additude, the patient-facing ADHD magazine. Fact is, there is little to no medical literature on this sort of stuff. That tells you something. For the TikTok generation, ADHD is not a diagnosis. It is an identity and a way of life. As such, there is nothing that cannot be explained by ADHD. To accomodate this new understanding of ADHD, neologisms need to be coined to capture this expansive concept of ADHD, explaining increasingly more facets of behavior with pseudo-medical sounding jargon.

ETA: There is nothing more tedious than a clinic of patients seeking treatment for ADHD who definitely don't have it. However, it is incredibly satisfying when a patient comes in with something else and they have ADHD which has gone undiagnosed, or more commonly misdiagnosed, for years, and you are able to identify and treat it.

 

[WisNeuro]

I've recently seen the younger millennial/gen zrs joining the neurodivergent movement. But, I strongly suspect that the majority of these individuals do not in fact have anything close to ADHD.

This is an area where, after identifying whether or not they actually have ADHD and need medication or not, it can be good to gently steer focus away from the rabbit hole of new terminology. Much of it is still very much in the research phase and not well supported. It may eventually be, but most isn't yet. Regardless, it usually doesn't help much to a person's day-to-day life to know where they score on some hastily created scale to capture some quantitative label of an opaque construct. Behaviorally, a functional analysis would be much higher yield. But, for some reason people want esoteric, complicated explanations for everything, when usually the simple explanation is the most correct (e.g., poor sleep hygiene for a host of things).

 

[PikminOC]

So many have tried their friends Adderall and now are sure they have the illness too. Stimulants are way overprescribed.

 

[PikminOC]

I feel I had a very good residency training experience but I've been inundated with adult ADHD referrals since coming out of training. I've also recently finished reading ADHD Nation by Alan Schwarz and guess I'm having a bit of an existential question about the nature of ADHD.

I'm not looking for resources on how to treat ADHD, I'm very comfortable with my pharmacology knowledge in that regards. More wondering about resources talking about how to better diagnose ADHD, impairments to look for, etc. It seems my patients have spent hours going down the rabbit hole of ADHD social media and come bombarding me with questions about emotional dysregulation, RSD, hyperfocus, time blindness, etc. I'm not even sure where to begin to find out more about these from an actual evidence based standpoint. The literature searches I've done have done been helpful in this regards.

Thanks!

Yes they are able to focus on those searches.

 

[deleted1100659]

I look a lot at past history. Has the patient lost multiple jobs due to trouble getting tasks completed on time, organizational issues, etc. Have they been on stimulants before, if so what was their response. Were they on stimulants as a kid? What was their grades before/after the stimulant?

Why are they asking for a stimulant now? What changed? If they were never on it before what made them decide they needed it now?

Adult ADHD is a pain sometimes but I agree it can be rewarding. Sometimes you have to be the bad guy and flat out say no. If there was an obvious history of struggle in terms of academic/career progression, and on interview they may even display some sx, and clean uds/no contraindications then im open minded.

 

[MacDonaldTriad]

There was a national push to stop undertreating pain. Then we had an opiate epidemic and mandatory trainings to educate us on the use of opiates and CURES was developed. Stimulants will be the next mandatory training to tackle this stimulant epidemic.

 

[deleted1100659]

There was a national push to stop undertreating pain. Then we had an opiate epidemic and mandatory trainings to educate us on the use of opiates and CURES was developed. Stimulants will be the next mandatory training to tackle this stimulant epidemic.

lets tackle the benzo epidemic too..not a fun experience inheriting countless patients on benzos when walking into a new job. At least with stimulants I can just stop it, have to do an agonizing taper with benzos..

 

[calvnandhobbs68]

There was a national push to stop undertreating pain. Then we had an opiate epidemic and mandatory trainings to educate us on the use of opiates and CURES was developed. Stimulants will be the next mandatory training to tackle this stimulant epidemic.

This is exactly my argument about a lot of this. Let's not be totally blind to the fact that there's a huge incentive to obtain stimulants, for both the patient's own cognitive enhancement but also significant street value to these meds. You know how many times people asked me if I had any Adderall in college (for no apparent reason besides I guess I did well in my biology major)? More than once, that's for sure. I get very highly suspicious of any late high schooler/college age kid coming in seeking an ADHD diagnosis. They all tend to be smart enough to read up on how to diagnose ADHD on Medscape and can easily lookup assessments like the ASRS and DIVA themselves (the older version is a free pdf online). This then gets into more of a philosophical debate about how restrictive we should be around cognitive enhancement with these meds and is also a very cultural thing...it's very very difficult to obtain stimulants in many other countries (similar to opioids).

I also agree with splik that there's also a portion of patients who start to build their identity around self diagnoses where basically any difficulty in life must be explainable by that diagnosis and any "provider" that does not accept this diagnosis and gives them what they want for this diagnosis is "gaslighting" them or some junk (I've seen this explicitly stated online).

I'm much more likely to diagnose this >13-14yo when I have collateral (parents, teachers, spouses, etc) that can give info consistent with the diagnosis at younger ages as well (not just this past school year or this past year). When I get the 18yo senior who forces his parents to come see me because he's getting Cs in AP US History and AP Calc but has no consistent history of ADHD sx or even poor school performance prior to this year and insists to me this must be from his "ADHD"....yeah I hate those evals. It's especially annoying in the era of "Done" and other ADHD telemedicine companies who basically diagnose someone with ADHD based on an ASRS and a 15 minute history.

 

[deleted1100659]

This is exactly my argument about a lot of this. Let's not be totally blind to the fact that there's a huge incentive to obtain stimulants, for both the patient's own cognitive enhancement but also significant street value to these meds. You know how many times people asked me if I had any Adderall in college (for no apparent reason besides I guess I did well in my biology major)? More than once, that's for sure. I get very highly suspicious of any late high schooler/college age kid coming in seeking an ADHD diagnosis. They all tend to be smart enough to read up on how to diagnose ADHD on Medscape and can easily lookup assessments like the ASRS and DIVA themselves (the older version is a free pdf online). This then gets into more of a philosophical debate about how restrictive we should be around cognitive enhancement with these meds and is also a very cultural thing...it's very very difficult to obtain stimulants in many other countries (similar to opioids).

I agree, I dont like scales for ADHD. I prefer to ask questions and see how the story aligns, I think people who are trying to obtain it illicitly will bs the heck out of a scale. People who try to obtain things illicitly, the more you ask, the more frustrated they get and they tend to slip up or let their frustration show. My favorite is "well if my ADHD was being treated then I could go out and find a job!".

In my adults my philosophy is that if you have severe enough ADHD causing a functional issue as to where you need treatment, ADHD is not a disorder that waxes and wanes during the day so I tend to only do long acting meds for the most part. Im more flexible in kids

Stimulants do have good long term efficacy in the right people though, unlike benzos. Some people do tremendously better on them and if it dramatically improves their marriage/career/etc and its obvious, then im fair in that regard.

I always get a UDS too.

 

[Mass Effect]

There was a national push to stop undertreating pain. Then we had an opiate epidemic and mandatory trainings to educate us on the use of opiates and CURES was developed. Stimulants will be the next mandatory training to tackle this stimulant epidemic.

I roll my eyes when I hear the above because it's inaccurate and hurts more patients than helps. Stimulants unlike opiates are not relatively new. They were not created and sold under false pretenses and blatant lies and misrepresentation of the data. The stimulant "epidemic" is not equivalent to opiates and alleging it is is wrong and discourages docs from adequately treating ADHD as we've seen in recent years.

 

[Mass Effect]

My favorite is "well if my ADHD was being treated then I could go out and find a job!".

I mean, that can be true. I did a "high risk" rotation during training in communities with low SES and exploding crime rates and of course lots of drugs. But there was a patient the attending and I diagnosed with severe ADHD that had likely been there since childhood but undiagnosed. It was literally life changing for this individual. We even did a presentation it. I don't want to reveal too much because something very specific happened that I can't say, but let's just say the whole family was so much better off that it should be a case report. I wonder what this person's life trajectory would have been if it had been diagnosed earlier. When you see severe ADHD you'll never forget the power of the diagnosis and treatment and the fact that it can affect not only your job but your ability to even get a job.

 

[calvnandhobbs68]

I roll my eyes when I hear the above because it's inaccurate and hurts more patients than helps. Stimulants unlike opiates are not relatively new. They were not created and sold under false pretenses and blatant lies and misrepresentation of the data. The stimulant "epidemic" is not equivalent to opiates and alleging it is is wrong and discourages docs from adequately treating ADHD as we've seen in recent years.

Dude what are you talking about opiates are newer than stimulants? People have been using opium since freaking 400BC...it's just been repackaged and more highly concentrated over time. Morphine existed since the early 1800s. Oxycodone has been around since the 1930s.

Amphetamine wasn't even synthesized until the the late 1800s. Methylphenidate wasn't synthesized until 1944 and wasn't really used until the 1970s. Adderall wasn't marketed until 1994 (basically because it failed as a weight loss drug).

We can argue how actually physically dependent people get to amphetamines/methylphenidate or not compared to opioids but one part of the argument shouldn't be that opioids were somehow "newer" than stimulants.

 

[Mass Effect]

Dude what are you talking about opiates are newer than stimulants? People have been using opium since freaking 400BC...it's just been repackaged and more highly concentrated over time. Morphine existed since the early 1800s. Oxycodone has been around since the 1930s.

That was worded in a rush as I was packing up. I meant specifically OxyContin, the "5th vital sign" and the language around under treating pain which the poster referenced. My point was that there has been no new movement, invention or rhetoric on the stimulant front unlike opiates in the 90s which led to the uptick in prescriptions due to false data and a national conversation of under treating pain basically twisting the hand of doctors to prescribe more and more while lying to them about the effects. This hasn't happened with stimulants so I doubt very much we're following the same path of opiates by prescribing Adderall and Ritalin.

 

[Merovinge]

That was worded in a rush as I was packing up. I meant specifically OxyContin, the "5th vital sign" and the language around under treating pain which the poster referenced. My point was that there has been no new movement, invention or rhetoric on the stimulant front unlike opiates in the 90s which led to the uptick in prescriptions due to false data and a national conversation of under treating pain basically twisting the hand of doctors to prescribe more and more while lying to them about the effects. This hasn't happened with stimulants so I doubt very much we're following the same path of opiates by prescribing Adderall and Ritalin.

That's ignoring a huge social media push about identifying w/ ADHD, influencers and big time rhetoric goes into this. Rates of diversion are very high in essentially every study ever done on stimulants as well. Heck it was about 50% of medical students taking them based on one widely published anonymous survey.

Don't get me wrong, as a child/adolescent psychiatrist I prescribe a lot of stimulants and am a huge fan of their life-changing abilities. But it is certainly not true that there is no new movement regarding ADHD, undiagnosed ADHD, and adult ADHD. To say otherwise is disingenuous.

 

[Mass Effect]

That's ignoring a huge social media push about identifying w/ ADHD, influencers and big time rhetoric goes into this. Rates of diversion are very high in essentially every study ever done on stimulants as well. Heck it was about 50% of medical students taking them based on one widely published anonymous survey.

Don't get me wrong, as a child/adolescent psychiatrist I prescribe a lot of stimulants and am a huge fan of their life-changing abilities. But it is certainly not true that there is no new movement regarding ADHD, undiagnosed ADHD, and adult ADHD. To say otherwise is disingenuous.

I don't consider social media influencers to be a "movement", certainly not one comparable to big pharma and their influence over the opioid epidemic. If there are doctors just handing out scripts for stimulants because this person or that person saw a SM on it, they should have their license yanked. But I'm not seeing a lot of this. I'm seeing the same irresponsible prescribing patterns of NPs and some MDs but no different than the ones prescribing benzos or even lamictal to everyone with a pulse. But the key difference is the national movement based on doctors being deceived and manipulated into prescribing.

If you have data on changes in prescribing patterns with stimulants, I'd like to see it. I'll admit I'm wrong if you have data on it.

 

[tr]

So many have tried their friends Adderall and now are sure they have the illness too. Stimulants are way overprescribed.

Good lord I hear this all the time. Adderall helps me focus, ergo I must have AD/HD.
Can we get some kind of PSA out there to explain to everyone that stimulants almost *universally* improve focus and that having your focus improved by amphetamine is not some kind of diagnostic gold standard?

 

[birchswing]

lets tackle the benzo epidemic too..not a fun experience inheriting countless patients on benzos when walking into a new job. At least with stimulants I can just stop it, have to do an agonizing taper with benzos..

Bills to curb prescribing or at least increase informed consent come up in state legislatures from time to time. They are usually patient-group initiated. You can sometimes testify virtually:

Massachusetts Benzodiazepine Bill Testimony for S.1260 & H.2117: An Act relative to benzodiazepines and non-benzodiazepine hypnotics - Benzodiazepine Information Coalition

On November 8, 2021, members of our coalition, the medical field and the general public testified before the Massachusetts Joint Committee on Mental Health, Substance Use and Recovery about two bills, S.1260 & H.2117: An Act relative to benzodiazepines and non-benzodiazepine hypnotics. Many...

www.benzoinfo.com

Good lord I hear this all the time. Adderall helps me focus, ergo I must have AD/HD.
Can we get some kind of PSA out there to explain to everyone that stimulants almost *universally* improve focus and that having your focus improved by amphetamine is not some kind of diagnostic gold standard?

This was interestingly a test that a CAP I saw in the late 1990s used. He said my response to Adderall would determine whether I had ADHD, and that people with ADHD would do better and those without it would do worse. I kind of remember that being a refrain at the time—the paradoxical effect of the stimulant on the person with ADHD. He didn't seem to think there was any other diagnostic. Of course, he also steadfastly did not believe in therapy, so he probably didn't value neuropsych testing.

 

[PikminOC]

I roll my eyes when I hear the above because it's inaccurate and hurts more patients than helps. Stimulants unlike opiates are not relatively new. They were not created and sold under false pretenses and blatant lies and misrepresentation of the data. The stimulant "epidemic" is not equivalent to opiates and alleging it is is wrong and discourages docs from adequately treating ADHD as we've seen in recent years.

Yet so many people suffer from an Adderall deficiency...

 

[PikminOC]

That was worded in a rush as I was packing up. I meant specifically OxyContin, the "5th vital sign" and the language around under treating pain which the poster referenced. My point was that there has been no new movement, invention or rhetoric on the stimulant front unlike opiates in the 90s which led to the uptick in prescriptions due to false data and a national conversation of under treating pain basically twisting the hand of doctors to prescribe more and more while lying to them about the effects. This hasn't happened with stimulants so I doubt very much we're following the same path of opiates by prescribing Adderall and Ritalin.

Theres alot of new rhetoric. When I was in medical school stims were not as prescribed as they are now for cognitive enhancement. It's all about keeping up with the other students.

 

[clausewitz2]

Can we get some kind of PSA out there to explain to everyone that stimulants almost *universally* improve focus and that having your focus improved by amphetamine is not some kind of diagnostic gold standard?

Yeah, I have on occasions used the line that the military gives people amphetamines for certain responsibilities on a regular basis, and it is not doing this because it believes they have ADHD.

 

[calvnandhobbs68]

Yeah, I have on occasions used the line that the military gives people amphetamines for certain responsibilities on a regular basis, and it is not doing this because it believes they have ADHD.

Right or literally all the (Allies and Axis) armed forces in WWII who got hyped up on amphetamines to get hyperfocused and increase output. Nah I bet they just all had adult onset ADHD that needed to be treated.

 

[WisNeuro]

Right or literally all the (Allies and Axis) armed forces in WWII who got hyped up on amphetamines to get hyperfocused and increase output. Nah I bet they just all had adult onset ADHD that needed to be treated.

Don't forget the golden era of baseball when you freely had bubblegum, sunflower seeds, and greenies freely available in the dugout and clubhouse.

 

[romanticscience]

Being a major league baseball player a risk factor for ADHD? LOL

Prevalence of Adderall among players caused MLB to limit its use

Adderall is an amphetamine known for treating attention-deficit hyperactivity disorder (ADHD). But the high number of players taking Adderall has led Major League Baseball to designate it as a performance-enhancing drug and sharply limit its use.

www.inquirer.com

 

[Mass Effect]

Theres alot of new rhetoric. When I was in medical school stims were not as prescribed as they are now for cognitive enhancement. It's all about keeping up with the other students.

Depends on the population you're referring to. College kids? I haven't seen them being prescribed Adderall for cognitive enhancement in non-ADHD people. The ones taking it without ADHD seem to get them illegally. Older patients with dementia? That was a thing even when I was in med school. These aren't new narratives.

 

[Mass Effect]

Being a major league baseball player a risk factor for ADHD? LOL

Prevalence of Adderall among players caused MLB to limit its use

Adderall is an amphetamine known for treating attention-deficit hyperactivity disorder (ADHD). But the high number of players taking Adderall has led Major League Baseball to designate it as a performance-enhancing drug and sharply limit its use.

www.inquirer.com

Now THAT's a new narrative.

 

[WisNeuro]

Now THAT's a new narrative.

Been going on for a while now, but I have a few colleagues who do these evals, so it's been on my radar or a while.

 

[MacDonaldTriad]

There is no doubt that ADHD is both under and over treated. It is in a similar proportion to how Abilify is a mixed antagonist/agonist. ADHD is 95% over treated in adults and 5% undertreated in adults. As I read the responses above my last post, I'm gratified that people see this. You can make a good living treating adult ADHD, but your patients come to you because other psychiatrist said no. You might be right some proportion of the time, but what is your yes to no ratio given you are further down the recommendation chain?

 

[PikminOC]

Now THAT's a new narrative.

I've seen this with football too

 

[PikminOC]

Don't forget the weedarall combo!

 

[calvnandhobbs68]

Now THAT's a new narrative.

These stories are from 8-10 years ago.

Adderall the new drug of choice for many major-leaguers

Adderall is legal and easily obtainable, but also dangerous if abused. Use in the major leagues has reached an absurd level.

www.cbssports.com

"I've seen doctors who want to be good guys," Dr. Lustberg says. "A patient says he has [ADD], so the doctor says, 'Yeah I think you have it. You're my friend, blah blah blah, you're telling me you can't focus.' So he prescribes it. He has a degree, so who's to say?"

 

[littlefred]

If you think about it, it's very easy filling a practice of high-paying patients if you freely write for stimulants. Have them do a self-questionnaire and BAM, you have ADHD.

Then after a bit if they become anxious... now you put them on a benzodiazepine. Now you have patients with two controlled substances that are going to have a hard time leaving your services.

Look around and you will see clinics that do this and are doing very well financially. No regulatory agency seems to bat an eye and you can "rationalize" why they medication regimen you have is working for the patient.

$$$ trumps all clinical reasoning for some physicians and midlevels.

 

[PikminOC]

I feel I had a very good residency training experience but I've been inundated with adult ADHD referrals since coming out of training. I've also recently finished reading ADHD Nation by Alan Schwarz and guess I'm having a bit of an existential question about the nature of ADHD.

I'm not looking for resources on how to treat ADHD, I'm very comfortable with my pharmacology knowledge in that regards. More wondering about resources talking about how to better diagnose ADHD, impairments to look for, etc. It seems my patients have spent hours going down the rabbit hole of ADHD social media and come bombarding me with questions about emotional dysregulation, RSD, hyperfocus, time blindness, etc. I'm not even sure where to begin to find out more about these from an actual evidence based standpoint. The literature searches I've done have done been helpful in this regards.

Thanks!

They all have Adderall deficiency.

 

[Stagg737]

Good lord I hear this all the time. Adderall helps me focus, ergo I must have AD/HD.
Can we get some kind of PSA out there to explain to everyone that stimulants almost *universally* improve focus and that having your focus improved by amphetamine is not some kind of diagnostic gold standard?

This is why I like to focus on the other ADHD symptoms in those I'm treating. Yea, focus got better, obviously. What about impulsivity though? Are you interrupting people less during conversations? Are your conversations better? Are you losing/misplacing things less? How about motivation? Is it easier to get started on household chores or work? Are you able to actually finish the task or stick with most of it? Can you more easily ignore outside stimuli?

I try and downplay the focus aspect and look at how their overall QoL changes that seem less obvious unless asked. Imo the best is when they can bring a spouse or parent to the appointment and ask them what the difference has been. I've found those close to ADHD patients benefit almost as much from the stimulant as the patient does

Yeah, I have on occasions used the line that the military gives people amphetamines for certain responsibilities on a regular basis, and it is not doing this because it believes they have ADHD.

I actually really like this. We were recently talking about "go packs" for pilots, might start bringing this into discussions with patients who don't clearly have ADHD.

 

[Orgone]

I'm getting back into private practice (cash this time) in a new city with lots of college students. I will be explicitly stating that I DO NOT TREAT ADHD OR PRESCRIBE STIMULANTS. Just like that, in big capital letters on the top of my webpage. This will probably cost me 80% of new referrals, but will save me 98% of headaches. Absolutely worth it.

In my old insurance practice, people coming in for ADHD were: 60% definitely didn't have it, 10% definitely did, and 29% were in a probably-don't-but-maybe gray zone. About 1% presented acutely high out of their minds. No idea what else they had.

The only ADHD patients who were satisfying to treat were the ones who didn't come in for ADHD. They came in for anxiety or depression, and over multiple sessions showed obvious signs of actual ADHD, and responded like a miracle when treated. The couple of those I had were in fact my favorite patients of all.

In conclusion, I formally invite the OP to join me in flexing some PP autonomy and just avoiding the whole charade.

Also, one anecdote for anyone doubting the big market push : my spouse, an internist, was looking for telemed work last year, and applied to an advertised spot for supposedly doing urgent care visits in a "new exciting tech company platform", also cofounded in partnership with Big Name University. Spouse was asked point blank if willing to prescribe stimulants, and on replying negatively, was told "thanks for talking with us we'll keep your CV on file." I checked out their website, and the big button next to "urgent care telemed" or whatever was "Get your ADHD treatment online!!!"

 

[AcronymAllergy]

For some of the newer faux-terminology, Google may be your best bet with how quickly some of it probably changes/develops. I don't have good recommendations beyond that.

In your own practice, if you want to assess for it but are hoping to cut down on some of the BS, you could require that all potential patients provide you multiple collateral contacts to interview, including someone who knows them well currently and someone who knew them well in childhood, the latter particularly if they're unable to provide school records and/or other evidence of clinically-significant multi-domain distress or impairment while they were growing up.

As for scales and other measures, I would second the recommendation for the DIVA-5, with the downside being that it can take a little while to get through (and it's no longer free, although the fee is nominal). The Barkley Adult ADHD Rating Scale is ok but face-valid. The Barkley Deficits in Executive Functioning Scale is more wide-ranging than just ADHD, but also comes with short- and long-forms as well as an informant version (sort of like the Connors scales for kiddos). The Clinical Assessment of Attention Deficit-Adult (CAT-A) is also decent and has current and retrospective report sections; I like the retrospective portion on it better than the Wender-Utah (WURS), but the latter is also an option.

 

[calvnandhobbs68]

For some of the newer faux-terminology, Google may be your best bet with how quickly some of it probably changes/develops. I don't have good recommendations beyond that.

In your own practice, if you want to assess for it but are hoping to cut down on some of the BS, you could require that all potential patients provide you multiple collateral contacts to interview, including someone who knows them well currently and someone who knew them well in childhood, the latter particularly if they're unable to provide school records and/or other evidence of clinically-significant multi-domain distress or impairment while they were growing up.

As for scales and other measures, I would second the recommendation for the DIVA-5, with the downside being that it can take a little while to get through (and it's no longer free, although the fee is nominal). The Barkley Adult ADHD Rating Scale is ok but face-valid. The Barkley Deficits in Executive Functioning Scale is more wide-ranging than just ADHD, but also comes with short- and long-forms as well as an informant version (sort of like the Connors scales for kiddos). The Clinical Assessment of Attention Deficit-Adult (CAT-A) is also decent and has current and retrospective report sections; I like the retrospective portion on it better than the Wender-Utah (WURS), but the latter is also an option.

Yeah I guess to answer OP's question actually, I do have the Barkley book and I use the BAARS-IV (Barkley Adult ADHD scale) because 1) It's free once you buy it once and 2) It has a collateral component to it as well. I use the WURS as well for self reported retrospective symptoms...the thing I like about it is that only 25 of the questions were associated with ADHD and its not easy for the patient to figure out exactly which ones those are. However, all the free rating scales end up being pretty easy to lookup online if you send them home with the scales or have them fill them out prior to the visit.

CAT-A is a little pricey (similar to the adult/pediatric Conners), so for most of the good normed scales you end up having to pay a bit for them. However, an upside to that is that it's basically impossible for patients to get ahold of these scales or figure out the scoring system for them (part of the reason I like Conners too).

DIVA-5 is basically just a semi-structured interview which you have to block off a good chunk of time for (they recommend 1-1.5 hours), so you have to be prepared to dedicated basically a whole intake time slot just for that.

I've cut off almost all my young adult referrals though at this point because I'm getting tired of the 20yo "ADHD" referrals so pretty much all my intakes now are <18yo. I have been trying to figure out how to get a good self-report scale for teenagers though to track treatment response, as I've noticed that's a large gap in assessment (if they're 17-18yo I'll end up using the BAARS to try to track sx over time).

 

[AcronymAllergy]

Yeah I guess to answer OP's question actually, I do have the Barkley book and I use the BAARS-IV (Barkley Adult ADHD scale) because 1) It's free once you buy it once and 2) It has a collateral component to it as well. I use the WURS as well for self reported retrospective symptoms...the thing I like about it is that only 25 of the questions were associated with ADHD and its not easy for the patient to figure out exactly which ones those are. However, all the free rating scales end up being pretty easy to lookup online if you send them home with the scales or have them fill them out prior to the visit.

CAT-A is a little pricey (similar to the adult/pediatric Conners), so for most of the good normed scales you end up having to pay a bit for them. However, an upside to that is that it's basically impossible for patients to get ahold of these scales or figure out the scoring system for them (part of the reason I like Conners too).

DIVA-5 is basically just a semi-structured interview which you have to block off a good chunk of time for (they recommend 1-1.5 hours), so you have to be prepared to dedicated basically a whole intake time slot just for that.

I've cut off almost all my young adult referrals though at this point because I'm getting tired of the 20yo "ADHD" referrals so pretty much all my intakes now are <18yo. I have been trying to figure out how to get a good self-report scale for teenagers though to track treatment response, as I've noticed that's a large gap in assessment (if they're 17-18yo I'll end up using the BAARS to try to track sx over time).

That's a good point about the WURS, and fair on the CAT-A's price; the last time I used it, my institution was paying for my testing supplies. The Barkley scales are more appealing from that perspective since, like you've said, they're free to copy once you buy the books.

Unfortunately, I don't have much advice to offer for tracking treatment progress in teens, as I've not worked with that population in years.

 

[Candidate2017]

It seems my patients have spent hours going down the rabbit hole of ADHD social media and come bombarding me with questions about emotional dysregulation, RSD, hyperfocus, time blindness, etc.

After seeing lots of "attention" patients, it becomes more of a gestalt. If my mind wanders while someone is relaying a cogent, linear 15 minute history of their life long struggles with attention and can convey their complete DSM-5 symptoms, then I usually have the answer as to whether it's ADHD. It's not. Also, I find it hard to believe most people with legit ADHD would be able to read through all those nonsense theories.

In residency, I had a lot of new evals for "attention". 90% were stimulant seekers. Generally, the legit "undiagnosed" ADHD patients were forced by their family/friends or boss to see psychiatry. They were indifferent to their ADHD despite its effects, didn't want meds, and/or were indifferent to continuing meds, sometimes complaining of feeling strange on stimulants. They'd often stopped their stimulants, never to be heard from again after several no-shows. This is the exact same behavior (noncompliance/unwillingness to medicate) you see in patients with serious medical illnesses like HTN, DM, CHF, CKD, schizophrenia, etc.

ADHD is a neurodevelopmental disorder so it's hard to go undiagnosed or escape the attention of parent, teacher or authority figures. The trickiest case is where a patient grows up in an unstable environment without authority figures and currently uses meth or cocaine. It's hard to say if they're a substance user or a substance user medicating their ADHD. In practice, it's a no go.

There are also new evals who had a childhood ADHD diagnosis, were off their meds for a while, and want to restart them. Usually in response to a new endeavor like a new job. They almost always have an underlying issue like depression or anxiety. Or forging their prior psychiatrist's scripts.

 

[Mass Effect]

I'm getting back into private practice (cash this time) in a new city with lots of college students. I will be explicitly stating that I DO NOT TREAT ADHD OR PRESCRIBE STIMULANTS. Just like that, in big capital letters on the top of my webpage. This will probably cost me 80% of new referrals, but will save me 98% of headaches. Absolutely worth it.

In my old insurance practice, people coming in for ADHD were: 60% definitely didn't have it, 10% definitely did, and 29% were in a probably-don't-but-maybe gray zone. About 1% presented acutely high out of their minds. No idea what else they had.

The only ADHD patients who were satisfying to treat were the ones who didn't come in for ADHD. They came in for anxiety or depression, and over multiple sessions showed obvious signs of actual ADHD, and responded like a miracle when treated. The couple of those I had were in fact my favorite patients of all.

In conclusion, I formally invite the OP to join me in flexing some PP autonomy and just avoiding the whole charade.

Also, one anecdote for anyone doubting the big market push : my spouse, an internist, was looking for telemed work last year, and applied to an advertised spot for supposedly doing urgent care visits in a "new exciting tech company platform", also cofounded in partnership with Big Name University. Spouse was asked point blank if willing to prescribe stimulants, and on replying negatively, was told "thanks for talking with us we'll keep your CV on file." I checked out their website, and the big button next to "urgent care telemed" or whatever was "Get your ADHD treatment online!!!"

I mean, ADHD is a psychiatric illness so it doesn't surprise me that your spouse was nixed for refusing to treat it. I don't agree with these online centers that treat ADHD after a 15 minute appt but I also think those of you refusing to treat a legitimate psychiatric illness are worsening the stigma and opening the market for sham companies.

 

[Mass Effect]

In your own practice, if you want to assess for it but are hoping to cut down on some of the BS, you could require that all potential patients provide you multiple collateral contacts to interview, including someone who knows them well currently and someone who knew them well in childhood, the latter particularly if they're unable to provide school records and/or other evidence of clinically-significant multi-domain distress or impairment while they were growing up.

I told myself I was going to give up on this thread and then decided that I had to continue reading because the information some of you put out there is ridiculous. Someone comes to see me at age 25 after losing 2 jobs and flunking out of college and I guarantee my question is not going to be "who knew you 20 years ago? Are they like your FB friend and can you give them this questionnaire to fill out?"

Come on people. Obviously don't give med seekers meds without appropriate workup and diagnosis, but requiring people to jump through a thousand hoops to prove how bad they want it just because we can is punitive. You know who's going to jump through your hoops? The drug dealer who wants to sell. The addict who needs the high. You know who isn't going to jump through your hoops? The patient with legitimate ADHD who is trying like hell to hold it together at work and at home.

 

[Mass Effect]

In residency, I had a lot of new evals for "attention". 90% were stimulant seekers. Generally, the legit "undiagnosed" ADHD patients were forced by their family/friends or boss to see psychiatry. They were indifferent to their ADHD despite its effects, didn't want meds, and/or were indifferent to continuing meds, sometimes complaining of feeling strange on stimulants. They'd often stopped their stimulants, never to be heard from again after several no-shows. This is the exact same behavior (noncompliance/unwillingness to medicate) you see in patients with serious medical illnesses like HTN, DM, CHF, CKD, schizophrenia, etc.

This may have been your experience, but as a general rule, this is not the norm and it's inaccurate for anyone to think this is what a typical ADHD patient looks like. Most ADHD patients who are treated with stimulants have life-changing effects from it. The non-compliant ones likely don't have ADHD.

ADHD is a neurodevelopmental disorder so it's hard to go undiagnosed or escape the attention of parent, teacher or authority figures.

It's "hard" perhaps, but not the least bit impossible. People do get through school making B's or C's when they were fully capable of making A's, but no one realizes it. Maybe I was just lucky in that my residency (large academic center) spent quite a bit of time on appropriately diagnosing ADHD. The drug seekers are using online sham companies, but the patients who are really suffering are not doing that. In many cases, they don't even know what's wrong or they read about ADHD and realize it describes their life.

The trickiest case is where a patient grows up in an unstable environment without authority figures and currently uses meth or cocaine. It's hard to say if they're a substance user or a substance user medicating their ADHD. In practice, it's a no go.

What do you mean a no go? There's evidence that treating ADHD in someone who has it can help tremendously in their recovery from cocaine.

There are also new evals who had a childhood ADHD diagnosis, were off their meds for a while, and want to restart them. Usually in response to a new endeavor like a new job. They almost always have an underlying issue like depression or anxiety. Or forging their prior psychiatrist's scripts.

Or maybe they just went off their meds and want to restart because they realize how much better they were with it. "Almost always" is an overstatement to a large degree.

 

[calvnandhobbs68]

It's "hard" perhaps, but not the least bit impossible. People do get through school making B's or C's when they were fully capable of making A's, but no one realizes it. Maybe I was just lucky in that my residency (large academic center) spent quite a bit of time on appropriately diagnosing ADHD. The drug seekers are using online sham companies, but the patients who are really suffering are not doing that. In many cases, they don't even know what's wrong or they read about ADHD and realize it describes their life.

No I think this gets into the point of are we selling cognitive enhancement with stimulants or treating a illness causing actual significant impairment. Seriously, I'd be pretty hard pressed saying that giving someone Concerta to get them from a B to an A in their college classes is "appropriately diagnosing ADHD". This is the same language that the "ADHD centers" use....everyone has ADHD and everyone could use a little cognitive enhancement. I mean yeah, sure, in the same way I could probably use a nose job or liposuction cause I suffer from an "attractiveness deficiency", I think a lot of this really comes down to your philosophical stance on this issue.

My philosophical stance is generally I need to see real evidence backed up by collateral sources of significant impairment from a disorder I'm going to treat with a controlled medication I know has a high risk for diversion and high street value in the young adult population. Are there exceptions? Sure, but they're generally people I'm suspecting myself may have ADHD when we're doing different things that don't seem to be working, not the 23yo patient that walks into my office saying "yeah doc I have terrible problems concentating and here are all the DSM 5 criteria for inattentive ADHD, no I don't have any school records, no you can't talk to my spouse and no I don't think I could get any info from my parents, but I think I have ADHD right?".

 

[splik]

ADHD is a neurodevelopmental disorder so it's hard to go undiagnosed or escape the attention of parent, teacher or authority figures.

If only that were so. Though there were comments on report cards from teachers about my "daydreaming", behavioral problems, lack of effort, poor attendance etc, I sailed through school with good grades. Med school I totally couldn't cope. It was on ordeal. Adulting has been an ordeal for me. I've never been able to hand in assignments on time. I never make deadlines. I lose things all the time. I am pathologically incapable of being on time. I constantly get threatened with losing my credentialing because of being behind with notes (sometimes 6 months behind) even though my patient volume is embarrassingly low. Anyone who knows me superficially thinks I am "high functioning" but people who know me well are like "how can you live like this?"

I have seen quite a few physicians who are like me (and can spot it a mile away). it's not uncommon for intelligent people to compensate in childhood and struggle later in life.

 

[calvnandhobbs68]

If only that were so. Though there were comments on report cards from teachers about my "daydreaming", behavioral problems, lack of effort, poor attendance etc, I sailed through school with good grades. Med school I totally couldn't cope. It was on ordeal. Adulting has been an ordeal for me. I've never been able to hand in assignments on time. I never make deadlines. I lose things all the time. I am pathologically incapable of being on time. I constantly get threatened with losing my credentialing because of being behind with notes (sometimes 6 months behind) even though my patient volume is embarrassingly low. Anyone who knows me superficially thinks I am "high functioning" but people who know me well are like "how can you live like this?"

I have seen quite a few physicians who are like me (and can spot it a mile away). it's not uncommon for intelligent people to compensate in childhood and struggle later in life.

Well...no. You're kind of proving the point. One would have been able to pick up on the teacher comments (which is something I always ask parents about, what kind of feedback are the teachers giving, not just what kind of grades is Johnny getting). One would have gotten a history of constantly turning in work late, which is something else teachers would have picked up on. It did not escape the attention of teachers. This is the classic description of "smart kid but can't really seem to pull him/herself together" who I give a trial of stimulants all the time. There is historical evidence of impairment.

 

[Mass Effect]

No I think this gets into the point of are we selling cognitive enhancement with stimulants or treating a illness causing actual significant impairment. Seriously, I'd be pretty hard pressed saying that giving someone Concerta to get them from a B to an A in their college classes is "appropriately diagnosing ADHD".

Who said you should do that? I definitely didn't. The ADHD kid making B's and C's in grade school, probably with mom and dad's help, is likely flunking out of college or struggling way more than getting B's. It is not cognitive enhancement if the person really has the disorder. It's treating an illness, the result of which is likely better performance.

This is the same language that the "ADHD centers" use....everyone has ADHD and everyone could use a little cognitive enhancement.

What language? What are you talking about?

I mean yeah, sure, in the same way I could probably use a nose job or liposuction cause I suffer from an "attractiveness deficiency", I think a lot of this really comes down to your philosophical stance on this issue.

No it comes from the evidence supporting it. I was like most of the posters on this thread when I entered residency because med school drilled it in my head that while stimulants are the treatment for ADHD, it's bad and harmful and people abuse it and divert it and besides, there's no such thing as someone with ADHD not diagnosed in childhood. It didn't help that my psych preceptor used to say if they're not on meds by high school, they don't have ADHD. Then I got to residency and learned the science thanks to attendings who encouraged us to read and discuss. We had a strong addiction program so we were taught a lot about appropriate diagnosis and treatment and they wanted to make sure we were comfortable enough that we weren't giving out stimulants to everyone and at the same time, that we weren't with holding care because of our own biases, prejudices and fears.

My philosophical stance is generally I need to see real evidence backed up by collateral sources of significant impairment from a disorder I'm going to treat with a controlled medication I know has a high risk for diversion and high street value in the young adult population.

Even Seroquel has street value.

Proper workup is very important and collateral is fine. But it's my opinion that requiring someone to find someone who know them 20 or 30 years ago to reflect on their behavior is stupid. If parents are still in their lives and patient is willing I think that's fine. But parents aren't always around and patients don't always have great relationships with them. The evidence I use is scales, history and sometimes, neuropsych testing if necessary. I rule out everything else of course. If collateral is available, even better but I don't punish the patient because there's no one who can vouch for their daydreaming 30 years ago. Collateral also doesn't tell you much in most cases. In cases where someone took note, mom or dad can tell you that Joey was running around the classroom. But in those cases, the diagnosis has probably already been made. In cases where inattention was predominant, likely no one picked up on it. When getting collateral, Mom might say Joey was lazy or Joey was late getting work in, but even that doesn't nail the diagnosis. So if it doesn't confirm it, then not having collateral shouldn't confirm not having it.

Unless I have reason to believe a patient is drug seeking, my inclination is to treat according to standard of care which in the case of ADHD is stimulants. I will treat until I suspect abuse. I may get UDS. I always check PMP. I do the same workup I would for any other illness. But I don't make patients jump through a thousand hoops to prove they have ADHD. It's not their fault the treatment can be risky. I go over those risks and they know that I don't do early refills and if there's any funny business, we go to non-stimulants.

Psychiatrists really need to get more comfortable with properly assessing drug addiction/drug seeking/diversion versus legitimate patient symptoms. It seems many in our field just don't want to deal with it. This is why there are online places that advertise to our patients.

Are there exceptions? Sure, but they're generally people I'm suspecting myself may have ADHD when we're doing different things that don't seem to be working, not the 23yo patient that walks into my office saying "yeah doc I have terrible problems concentating and here are all the DSM 5 criteria for inattentive ADHD, no I don't have any school records, no you can't talk to my spouse and no I don't think I could get any info from my parents, but I think I have ADHD right?".

So if you don't suspect it, then it must not be there. Got it.

Curious, do you have your elementary school records? I sure as hell don't. I don't have ADHD but if I did and I wasn't diagnosed, I'd be out of luck if I came to your office. My parents are still in my life, but I don't tend to involve them in my health nor do I have any faith they'd remember anything about my childhood. My work was my business and as long as I didn't fail, they didn't really care what I did. I have a single friend from 3rd grade. Do I think he'd remember if I daydreamed? That'd be a big fat no. And even if he did, I'd rather go without treatment than call him up and ask him to fill out a form so I can get Ritalin.

Like I said, you know who WILL do all the stuff you require? The drug seekers. You know who won't? People with legitimate illness.

 

[Mass Effect]

Well...no. You're kind of proving the point. One would have been able to pick up on the teacher comments (which is something I always ask parents about, what kind of feedback are the teachers giving, not just what kind of grades is Johnny getting). One would have gotten a history of constantly turning in work late, which is something else teachers would have picked up on. It did not escape the attention of teachers. This is the classic description of "smart kid but can't really seem to pull him/herself together" who I give a trial of stimulants all the time. There is historical evidence of impairment.

Are you talking about kids? In the case of kids I agree with you that collateral is vital especially from teachers. I'm talking about the 38 year old in my office who has repeatedly been fired, always loses things, is always late, has a history of doing what he needed in school and doing poorly or flunking out of college or grad school. The 38 year old may not know the comments teachers made to his parents if he was doing well or if parents weren't involved. He may tell you he daydreamed, but he doesn't have his report cards. He doesn't want you talking to his parents or friends about his medical problems (esp with the stigma around psychiatric disorders). His lack of collateral shouldn't exclude him from treatment.

 

[AcronymAllergy]

I told myself I was going to give up on this thread and then decided that I had to continue reading because the information some of you put out there is ridiculous. Someone comes to see me at age 25 after losing 2 jobs and flunking out of college and I guarantee my question is not going to be "who knew you 20 years ago? Are they like your FB friend and can you give them this questionnaire to fill out?"

Come on people. Obviously don't give med seekers meds without appropriate workup and diagnosis, but requiring people to jump through a thousand hoops to prove how bad they want it just because we can is punitive. You know who's going to jump through your hoops? The drug dealer who wants to sell. The addict who needs the high. You know who isn't going to jump through your hoops? The patient with legitimate ADHD who is trying like hell to hold it together at work and at home.

There are situations where collateral may not be needed, sure. If they've got multiple examples of recent distress/impairment and the symptom onset and course seem consistent with ADHD, and you have faith in that self-report, have at it. You definitely don't need a rating scale or questionnaire for everything. But in situations where the potential causal factors of that impairment are unclear, the person is a less-than-great historian, or the impairment itself is iffy, I don't think it's ridiculous or overreaching at all to ask the patient if you can have a 15-20 minute conversation with a parent to get information about early-life symptoms, and/or a spouse or friend or partner to get someone else's perspective on how they are currently outside your office. Especially because those conversations may give you additional information as to other contributing factors (even if there's also ADHD) and/or treatment recommendations.

Edit to say that I also think it's entirely possible for people to make it through childhood and adolescence without being diagnosed, for myriad reasons. They are intellectually high-functioning and able to compensate, they have great support systems, they have horrid school and support systems and no one bothered to care because all the students are "horrible" or they were written off as a bad kid, etc. I don't think we should make ADHD, or any diagnosis, difficult just for the sake of making it difficult, nor should we punish future patients for our own past patient experiences, which may have been colored by the setting we worked/trained in. But I do think ADHD unfortunately is often misdiagnosed because of the poor job done in assessing it.

 

[Old&InTheWay]

Aside from the very good teaching and supervision I have gotten in residency, a really impactful part of my education in ADHD was marrying a spouse with ADHD and having a child with ADHD. I don't necessarily think this should be added to the ACGME competencies, but the degree to which my understanding of the subtle nuances of ADHD, the ways in which it can impact one's life and my empathy towards those who have it has evolved is substantial.

I completely agree with the idea that it is cruel to make people jump through hoops to be diagnosed. I inherited several patients where there was a question of ADHD and they had been waiting 6+ months to see a neurophyschologist before the previous psychiatrist would make a diagnosis and start treatment. It was pretty clear to me after a few visits that both did indeed have ADHD and both have had remarkable improvement in their lives since starting treatment. I'm not comfortable with preventing people from living satisfying lives because someone might misuse or sell their meds.

That's not to say that I am giving out stimulants to anyone who asks for them, but rather if my clinical impression is that they do have ADHD, I'm likely going to start treatment, just as I do with any other psychiatric disorder.

 

[AcronymAllergy]

Waiting any amount of time for a neuropsychological evaluation to arrive at a diagnosis of ADHD is unnecessary and empirically unsupported, unless you're trying to potentially rule-in/out other conditions for which a neuropsych could be helpful. That's not to say a neuropsych eval can't be helpful for informing recommendations, but it definitely shouldn't hold up a diagnosis.