Why do people (residents) hate ADHD?

[luckrules]

Background: Applicant on the interview trail. Unsure where I’ll end up, maybe general psychiatry, some interest in child, addictions.

I’ve been talking to current residents and have been hearing variations on the theme “Well I was really interested in child, then I realized it was mostly just ADHD...” followed by lost interest.

I’ve never done a child rotation (supposedly weak at my institution, at least at the Med Student level), so I’ll admit my exposure is limited. But from my naive perspective, I could imagine ADHD being a really rewarding patient population to work with. I think there are many really effective interventions in multiple domains (pharma, behavior, mindfulness, built environment). Additionally, there are lots of interesting ways to think about ADHD from a social/cultural perspective so I feel like it would be fun exploring those. I guess I’m wondering why the residents I’m meeting were so turned off by it. Is it because the kids are tough and parents just expect you to “fix” them? Is it because the kids/parents don’t actually do any of things you suggest? Is it because families feel entitled to stimulants, etc.? Or is it something else?

Thanks in advance!

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[Shikima]

Psychiatry has some of the lowest Interrater Reliability scores around is what I read.

 

[NickNaylor]

I will freely admit that my knowledge of child psychiatry is very limited, and I have zero interest in CAP.

I’m not sure what to say about ADHD in particular, but some of the things you mention certainly plague CAP generally and are major reasons why I had no interest in it (despite, by the way, planning on doing pediatrics before ultimately going into psychiatry). What you mention - for example, being able to exert a strong and positive impact on a kid - is certainly a potential rewarding endeavor. But unlike adults, kids are beholden to the often horrible environments they come from with dysfunctional family dynamics, ambivalent parents, and an apparent disregard for psychiatric input into the care of their child. Obviously this does not describe all of CAP, but these were the major themes that I noticed when working on CAP services. It is frustrating working with parents who, sometimes, have near disdain for you, disregard your recommendations, and have absolutely zero insight into how their own behaviors are damaging their children. Of course, you still see these issues in adult psychiatry, but at that point your patient is an independent adult, and I find patients’ poor choices that result in self-destruction less heart-breaking than a child simply responding to and developing within their dysfunctional environment.

I have never heard of people “hating ADHD,” and while ADHD certainly seems to make up a large portion of CAP practice - much like depression and anxiety make up much of adult psychiatric practice - there is more to CAP than ADHD.

I guess I haven’t personally seen what you’re talking about, though some of the things you mention tend to be themes of CAP generally and not restricted to ADHD specifically.

 

[erg923]

Background: Applicant on the interview trail. Unsure where I’ll end up, maybe general psychiatry, some interest in child, addictions.

I’ve been talking to current residents and have been hearing variations on the theme “Well I was really interested in child, then I realized it was mostly just ADHD...” followed by lost interest.

I’ve never done a child rotation (supposedly weak at my institution, at least at the Med Student level), so I’ll admit my exposure is limited. But from my naive perspective, I could imagine ADHD being a really rewarding patient population to work with. I think there are many really effective interventions in multiple domains (pharma, behavior, mindfulness, built environment). Additionally, there are lots of interesting ways to think about ADHD from a social/cultural perspective so I feel like it would be fun exploring those. I guess I’m wondering why the residents I’m meeting were so turned off by it. Is it because the kids are tough and parents just expect you to “fix” them? Is it because the kids/parents don’t actually do any of things you suggest? Is it because families feel entitled to stimulants, etc.? Or is it something else?

Thanks in advance!

Because most of the time its not. And people prefer to blame their undiciplined or abberant behavior on a disorder rather than on themselves.

 

[Shikima]

Are Child patient's easier to treat than Adults?

 

[nitemagi]

21 paths: "Resetting the Bar" | Paul R. Puri, MD

 

[erg923]

21 paths: "Resetting the Bar" | Paul R. Puri, MD

I actually had a psychiatrist tell me last week gives repeat TOVAs to assist in stimulant titration in his practice, because if they don't have AD/HD, they will do worse on the TOVA with stimulant medications. He sounded old.

 

[wolfvgang22]

I did a child fellowship and don't hate treating ADHD at all. It is the easiest thing in Psychiatry to me. It is satisfying to see kids improve in school. Not bad for the bread and butter routine of a child Psychiatrist!
Now, ODD and Conduct Disorder are often co-morbid and more of a challenge. It is true that parenting is often the real problem there.

In a lot of ways I prefer treating children and helping parents compared to treating many adults. Kids are more resilient and have lots of potential for improvement. I don't seen kids now because it doesn't pay more than seeing adults yet takes more time. I would have to start my own practice in my area because there aren't many other child psych trained people in my region. I do miss it, though.

 

[MedMan80]

I did a child fellowship and don't hate treating ADHD at all. It is the easiest thing in Psychiatry to me. It is satisfying to see kids improve in school. Not bad for the bread and butter routine of a child Psychiatrist!
Now, ODD and Conduct Disorder are often co-morbid and more of a challenge. It is true that parenting is often the real problem there.

In a lot of ways I prefer treating children and helping parents compared to treating many adults. Kids are more resilient and have lots of potential for improvement. I don't seen kids now because it doesn't pay more than seeing adults yet takes more time. I would have to start my own practice in my area because there aren't many other child psych trained people in my region. I do miss it, though.

In CAP fellowship now and enjoying it, it's true that the ODD and conduct can improve with treating the ADHD (ODD more so)

 

[TexasPhysician]

I’m CAP and ADHD treatment is fun to me.

 

[Trismegistus4]

I'm an adult psychiatrist and I hate ADHD, because there is currently a huge epidemic of adults with no childhood history of it becoming convinced they have it and showing up in psychiatrists' offices demanding stimulants. I had 2 established patients ask me for stimulants today, and as I look at tomorrow's schedule it looks like that's the reason for my 8AM new patient coming in as well. As I have said in other threads, I have been completely blindsided by this in my current job, because I received absolutely ZERO education or experience with this issue in residency and have no idea what is the right thing to do with these people.

 

[erg923]

I'm an adult psychiatrist and I hate ADHD, because there is currently a huge epidemic of adults with no childhood history of it becoming convinced they have it and showing up in psychiatrists' offices demanding stimulants. I had 2 established patients ask me for stimulants today, and as I look at tomorrow's schedule it looks like that's the reason for my 8AM new patient coming in as well. As I have said in other threads, I have been completely blindsided by this in my current job, because I received absolutely ZERO education or experience with this issue in residency and have no idea what is the right thing to do with these people.

You should never have 8am patients, haha.

I would suspect that the vague endorsements and the cosmetic potential of the diagnosis and it subsequent treatment (especially in adults) makes it frustrating. And many times these symptoms are a sign of about a billion other life and psychiatric problems, right? And then, with adults, there is the whole lack of (cognitive) discipline aspect. As in, "your perceived restlessness and/or problems with concentration might just be a weakness for you as a person." Not necessarily this psychiatric disorder we known as "AD/HD."

This is why a thorough psychiatric/psychological evaluation, but not necessarily "testing," is so important for this population. All available psychiatric and neuroscience evidence points to this being a real entity that is hopelessly confounded by..... LIFE CIRCUMSTANCES.

 

[Trismegistus4]

You should never have 8am patients, haha.

I don't have a choice, but I actually chose for 8AM to be a new patient slot most days, because 8AM new patients are most likely to no-show. But if I didn't, this lady would just have gotten scheduled for 9 or 10, and it would be just as bad. Oh, did I mention her PCP documented at the visit at which she was referred, that she wanted Dyanavel because she tried her daughter's, and it "made her feel great" and suddenly "everything made sense," that she was "demanding" and became "quite upset" when he would not prescribe a stimulant, stating that her previous psychiatrist thought she might have ADHD and that the PCP knows her and should be able to read her past psych notes which were scanned into our system, that she was "desperate for med as does not want lose her job,*" and oh yeah, she has a history of bipolar disorder and alcohol abuse? Oh, also, he gave her a trial of Strattera, but of course after a few days she called in stating she was not going to take it because it made her sluggish and groggy. And he tried sending her to a community mental health agency, but they told her there they don't treat ADHD. (If I were in my own private practice, that's what I would say, but I've seen the section of our organization's website where it says we do treat ADHD.) Sigh; just another day in the life for me. You ADHD-lovers are welcome to see these people.

*This is my least favorite thing to deal with--when they try to guilt-trip or threaten you into prescribing a controlled substance because their life is going to fall apart if you don't.

 

[erg923]

I don't have a choice, but I actually chose for 8AM to be a new patient slot most days, because 8AM new patients are most likely to no-show. But if I didn't, this lady would just have gotten scheduled for 9 or 10, and it would be just as bad. Oh, did I mention her PCP documented at the visit at which she was referred, that she wanted Dyanavel because she tried her daughter's, and it "made her feel great" and suddenly "everything made sense,"

See my post previous below:

I actually had a psychiatrist tell me last week that he gives repeat TOVAs to assist in stimulant titration in his practice, because if they don't have AD/HD, they will do worse on the TOVA with stimulant medications. He sounded old.

 

[Trismegistus4]

I would suspect that the vague endorsements and the cosmetic potential of the diagnosis and it subsequent treatment (especially in adults) makes it frustrating. And many times these symptoms are a sign of about a billion other life and psychiatric problems, right? And then, with adults, there is the whole lack of (cognitive) discipline aspect. As in, "your perceived restlessness and/or problems with concentration might just be a weakness for you as a person." Not necessarily this psychiatric disorder we known as "AD/HD."

I definitely agree with that. With so many of these people, if you just run down a checklist they will endorse all the symptoms, but when you have them speak freely about their difficulties it becomes clear it's almost entirely a procrastination/motivation problem. But so what then? What do you tell them? To just try harder? They're still sitting right in front of you, saying "please, doc, DO SOMETHING! I'm about to get fired from my job/fail out of grad school!" etc. etc.

I actually had a psychiatrist tell me last week gives repeat TOVAs to assist in stimulant titration in his practice, because if they don't have AD/HD, they will do worse on the TOVA with stimulant medications. He sounded old.

I thought when you wrote "he sounded old," you meant he might not know what he was doing and his approach might be invalid. Were you saying he was experienced and therefore this might be a good approach?

 

[erg923]

I definitely agree with that. With so many of these people, if you just run down a checklist they will endorse all the symptoms, but when you have them speak freely about their difficulties it becomes clear it's almost entirely a procrastination/motivation problem. But so what then? What do you tell them? To just try harder? They're still sitting right in front of you, saying "please, doc, DO SOMETHING! I'm about to get fired from my job/fail out of grad school!" etc. etc.


I thought when you wrote "he sounded old," you meant he might not know what he was doing and his approach might be invalid. Were you saying he was experienced and therefore this might be a good approach?

I meant he was buying into some long ago clinical myth. Medication response, especially with this class of drugs, does not NOT equate to diagnostic validity. To hold on to such notions is unscientific and naive. When Haldol calms an agitated psychiatric patient, do we take this as evidence that they are/were psychotic or have schizophrenia? No. There is scant evidence for this as a method for treatment planning for AD/HD and does not even approach standard of care or "medically necessary" from a payors perspective.

From a quality of care/ROI perspective (assuming the dx is valid), I'm more concerned with whether or not they can pay attention in class and get homework assignments done on time, function in life, etc. than I am whether or not their results on some attention test in a nice quiet doctors office improves by half a standard deviation (if that). What does that really tell you about their actual function, right?

 

[wolfvgang22]

I don't have a choice, but I actually chose for 8AM to be a new patient slot most days, because 8AM new patients are most likely to no-show. But if I didn't, this lady would just have gotten scheduled for 9 or 10, and it would be just as bad. Oh, did I mention her PCP documented at the visit at which she was referred, that she wanted Dyanavel because she tried her daughter's, and it "made her feel great" and suddenly "everything made sense," that she was "demanding" and became "quite upset" when he would not prescribe a stimulant, stating that her previous psychiatrist thought she might have ADHD and that the PCP knows her and should be able to read her past psych notes which were scanned into our system, that she was "desperate for med as does not want lose her job,*" and oh yeah, she has a history of bipolar disorder and alcohol abuse? Oh, also, he gave her a trial of Strattera, but of course after a few days she called in stating she was not going to take it because it made her sluggish and groggy. And he tried sending her to a community mental health agency, but they told her there they don't treat ADHD. (If I were in my own private practice, that's what I would say, but I've seen the section of our organization's website where it says we do treat ADHD.) Sigh; just another day in the life for me. You ADHD-lovers are welcome to see these people.

*This is my least favorite thing to deal with--when they try to guilt-trip or threaten you into prescribing a controlled substance because their life is going to fall apart if you don't.

Well, it sounds like the PCP made it easier for you to say no appropriately in this case. Just say you agree with the PCP's assessment and you don't feel it is safe to give stimulants to someone who doesn't have ADHD. If some other doctor wants to enable a person seeking inappropriate medication, and disagree with the assessment of two previous physicians and take on that liability, they are free to do that.

 

[AcronymAllergy]

I'm an adult psychiatrist and I hate ADHD, because there is currently a huge epidemic of adults with no childhood history of it becoming convinced they have it and showing up in psychiatrists' offices demanding stimulants. I had 2 established patients ask me for stimulants today, and as I look at tomorrow's schedule it looks like that's the reason for my 8AM new patient coming in as well. As I have said in other threads, I have been completely blindsided by this in my current job, because I received absolutely ZERO education or experience with this issue in residency and have no idea what is the right thing to do with these people.

Assessing for ADHD in adults can be exceedingly frustrating, yep. Combine the issues mentioned in posts above with frequent lack of any sort of collateral childhood report/substantiation and the general non-specificity of the symptoms, and it's often a pain to tease apart. Although I would agree that in general, asking the patient "free-form" about their difficulties tends to work better than the yes/no symptom checklist style of interviewing. And once someone, somewhere in the past has told them they have ADHD and started them on a stim (often without more than maybe a screening symptom checklist or report of "trouble concentrating" during a brief office visit), they're completely sold on the idea. Try to suggest something else, and as you've said, it's not uncommon to have them essentially threaten to decompensate (e.g., "the only reason I was drinking everyday was because I couldn't get my Adderall; I don't want to start doing that again if it's taken away").

In children, the ability to get information from parents AND teachers, and ideally to perform classroom observation, can add to the diagnostic accuracy and confidence. Almost makes you wish you could hand a symptom checklist to someone's boss and then observe them while they're at work all day.

 

[Liquid8]

I definitely agree with that. With so many of these people, if you just run down a checklist they will endorse all the symptoms, but when you have them speak freely about their difficulties it becomes clear it's almost entirely a procrastination/motivation problem. But so what then? What do you tell them? To just try harder? They're still sitting right in front of you, saying "please, doc, DO SOMETHING! I'm about to get fired from my job/fail out of grad school!" etc. etc.

Adult ADHD wasn’t something that I dealt with much in my training, but there is a lot of demand in private practice so I figured it would be good to read up more. Just as how we wouldn’t accept a patient telling us that they are “hearing voices” as psychotic without asking further clarifying questions, I find that symptom checklists on their own are insufficient, and use the DIVA 2 questionnaire as a basis for my interviews to try and nut out what is going on.

Still, it can be tricky. On one hand I’ve had adult patients who have done very well on stimulants, but for the most part they had some childhood history and had been resisting or reluctant to seek treatment for a long time – I think this is often due to the stigma associated with mental health and ADHD which was much more prevalent at the time they were growing up. Generally they also seem more open to having any identified co-morbidities treated first, before going on stimulants.

I think I’ve largely avoided drug seekers and time wasters (due to my consultation fees and our local referral protocols), but a few months ago I received an abusive 8 page letter from a one off assessment who I felt did not have ADHD or require stimulants. Aside from being unable to describe any symptoms or provide any examples of ADHD, they had an extensive drug history, admitted to purchasing stimulants illegally and not noticing any improvements despite taking triple the usual dose, as well as a blanket refused to consider any other psychotropic medications. The ability of the patient to write such a lengthy diatribe also confirmed the Cluster B diagnosis.

What I did not expect was their referring doctor to call up and complain about my report. In the back of my mind I felt they had probably bought too much into the patient’s story, and there was a low likelihood that the all of the numerous psychiatrists who had seen him in the past had got it wrong in not diagnosing ADHD.

 

[digitlnoize]

I definitely agree with that. With so many of these people, if you just run down a checklist they will endorse all the symptoms, but when you have them speak freely about their difficulties it becomes clear it's almost entirely a procrastination/motivation problem.

But that's literally ADHD! Procrastination and lack of motivation are a key part of the syndrome of ADHD-I. Unfortunately, it's EXTREMELY common for ADHD, particularly the inattentive type, to go undiagnosed in childhood, particularly in higher functioning people, especially women. Then they get to college, away from the moms and dads who were helping pick up the slack and keep their lives together, and everything falls apart. It's very, very common. Don't neglect these people just because you think they "just don't have enough motivation".

 

[aim-agm]

But that's literally ADHD! Procrastination and lack of motivation are a key part of the syndrome of ADHD-I. Unfortunately, it's EXTREMELY common for ADHD, particularly the inattentive type, to go undiagnosed in childhood, particularly in higher functioning people, especially women. Then they get to college, away from the moms and dads who were helping pick up the slack and keep their lives together, and everything falls apart. It's very, very common. Don't neglect these people just because you think they "just don't have enough motivation".

Or do procrastination/motivation behavioral interventions before starting them on stimulants. I agree with you that a lot of ADHD doesn't get picked up until support systems disappear/fail or functional demands exceed their impaired capacity, yet there are still many people out there who don't have it together because of personal shortcomings that wouldn't benefit from pharmacotherapy.

 

[thoffen]

I patient with clear-cut ADHD (child or adult) and no significant comorbid conduct or character-related problems can be the absolute best patients in the world to treat. You can identify a real problem and make a big impact in their lives.

But you'll see a lot of comorbidities or confounders that make things less pleasant. The hardest patients for me are the ones with clear character level issues and gain related to ADHD diagnosis and treatment but whom I'm pretty sure also have ADHD.

 

[Candidate2017]

I don't have a choice, but I actually chose for 8AM to be a new patient slot most days, because 8AM new patients are most likely to no-show. But if I didn't, this lady would just have gotten scheduled for 9 or 10, and it would be just as bad. Oh, did I mention her PCP documented at the visit at which she was referred, that she wanted Dyanavel because she tried her daughter's, and it "made her feel great" and suddenly "everything made sense," that she was "demanding" and became "quite upset" when he would not prescribe a stimulant, stating that her previous psychiatrist thought she might have ADHD and that the PCP knows her and should be able to read her past psych notes which were scanned into our system, that she was "desperate for med as does not want lose her job,*" and oh yeah, she has a history of bipolar disorder and alcohol abuse? Oh, also, he gave her a trial of Strattera, but of course after a few days she called in stating she was not going to take it because it made her sluggish and groggy. And he tried sending her to a community mental health agency, but they told her there they don't treat ADHD. (If I were in my own private practice, that's what I would say, but I've seen the section of our organization's website where it says we do treat ADHD.) Sigh; just another day in the life for me. You ADHD-lovers are welcome to see these people.

*This is my least favorite thing to deal with--when they try to guilt-trip or threaten you into prescribing a controlled substance because their life is going to fall apart if you don't.

From my experience, FM docs hand out benzos and stimulants like candy. It takes a lot for a FM to refer a patient out to psych (i.e., the patient is a nightmare and the PCP can't stand the patient any longer). Garbage referrals. Refer them back to their PCP. The best FM docs I've met will refuse to treat psychiatric issues; they give a 1 month supply of psych meds and tell the patient to follow up with psych.

FM docs who have issues with stimulants (rare), will impose onerous follow up requirements (frequent visits and drug screens) and then fire the patient when they miss their follow up visit or drug screen. It's too underhanded and non-therapeutic for my taste. I'm up front about pointing out that demanding prescription methamphetamines will ruin their lives and it's in their best interest for me to say no. Drug seekers are like petulant children who respond to paternal or maternal figures who gently and firmly say, "No" out of a concern for their well being.

 

[erg923]

But that's literally ADHD! Procrastination and lack of motivation are a key part of the syndrome of ADHD-I. Unfortunately, it's EXTREMELY common for ADHD, particularly the inattentive type, to go undiagnosed in childhood, particularly in higher functioning people, especially women. Then they get to college, away from the moms and dads who were helping pick up the slack and keep their lives together, and everything falls apart. It's very, very common. Don't neglect these people just because you think they "just don't have enough motivation".

I think his point was that these are high base rate behaviors/traits in the general population, not to mention individuals with ANY psychiatric comorbidity (which is probably why they are scheduled with you in the first place), and the diagnostic process for AD/HD is troublesome/tricky and not fitting with the typical time alloted for most psychiatrists in the outpatient setting.

The situation your described could be attributed to literally scores of other factors and their combined effect. This is why this disorder is so tenuous (and frustrating) to diagnose in practice.

 

[Armadillos]

Skipped most the the thread, I think there are plenty of folks out there who at some level don't like treating ADHD because they assume that just because a patient likes the treatment that means something immoral is happening or it's somehow the easy way out to take a medication that works as well as stimulants.

My understanding is in scheme of medications stimulants are really very safe, probably orders of magnitudes safer than antipsychotics I would imagine.

 

[LasVagus]

In my third year of residency I inherited three different patients diagnosed with ADHD who were on stimulants and had some interesting characteristics in common. They all had measured IQs of over 130 and none of them experienced problems with concentration/attention until graduate school. I'm sure many would argue that IQ is not the same thing as attention and the fact that they have high IQs enabled them to compensate for attention difficulties in easier academic environments. However, I could not shake the feeling that I was essentially giving EPO to the former all-state high school distance runners who couldn't quite keep up in Division I.

 

[PikminOC]

Does the DEA come after physicians who have patients that share antipsychotics? Are people more or less likely to divert antipsychotics or stimulants? Trade which one for other drugs? More likely to abuse antipsychotics and lose them or want early fills?

 

[Armadillos]

Does the DEA come after physicians who have patients that share antipsychotics? Are people more or less likely to divert antipsychotics or stimulants? Trade which one for other drugs? More likely to abuse antipsychotics and lose them or want early fills?

You always mention the DEA, why are you so worried about them bothering you for using a FDA approved medication for its indication? Are there psychiatrists in your area who are getting into trouble for this? I've never heard of it around here.

Early refills are easy, just don't do them, easy as that.

 

[NickNaylor]

Does the DEA come after physicians who have patients that share antipsychotics? Are people more or less likely to divert antipsychotics or stimulants? Trade which one for other drugs? More likely to abuse antipsychotics and lose them or want early fills?

The only antipsychotic that I’ve heard of that has some degree of street value is quetiapine. I find it hard to believe that the DEA would even care given that it’s not a controlled substance unless you were involved in some kind of antipsychotic drug ring.

 

[ryerica22]

I will freely admit that my knowledge of child psychiatry is very limited, and I have zero interest in CAP.

I’m not sure what to say about ADHD in particular, but some of the things you mention certainly plague CAP generally and are major reasons why I had no interest in it (despite, by the way, planning on doing pediatrics before ultimately going into psychiatry). What you mention - for example, being able to exert a strong and positive impact on a kid - is certainly a potential rewarding endeavor. But unlike adults, kids are beholden to the often horrible environments they come from with dysfunctional family dynamics, ambivalent parents, and an apparent disregard for psychiatric input into the care of their child. Obviously this does not describe all of CAP, but these were the major themes that I noticed when working on CAP services. It is frustrating working with parents who, sometimes, have near disdain for you, disregard your recommendations, and have absolutely zero insight into how their own behaviors are damaging their children. Of course, you still see these issues in adult psychiatry, but at that point your patient is an independent adult, and I find patients’ poor choices that result in self-destruction less heart-breaking than a child simply responding to and developing within their dysfunctional environment.

I have never heard of people “hating ADHD,” and while ADHD certainly seems to make up a large portion of CAP practice - much like depression and anxiety make up much of adult psychiatric practice - there is more to CAP than ADHD.

I guess I haven’t personally seen what you’re talking about, though some of the things you mention tend to be themes of CAP generally and not restricted to ADHD specifically.

ADHD is not the bulk of CAP practice. The pediatricians handle ADHD on their own for the most part

 

[tr]

I definitely agree with that. With so many of these people, if you just run down a checklist they will endorse all the symptoms, but when you have them speak freely about their difficulties it becomes clear it's almost entirely a procrastination/motivation problem. But so what then? What do you tell them? To just try harder? They're still sitting right in front of you, saying "please, doc, DO SOMETHING! I'm about to get fired from my job/fail out of grad school!" etc. etc.

CBT for procrastination is a thing. If you don't care to provide that intervention, find a good psychologist and refer.

 

[hamstergang]

ADHD is not the bulk of CAP practice. The pediatricians handle ADHD on their own for the most part

It's been a while since I calculated it, but 1/3 - 1/2 of my patients (all CAP outpatient) have ADHD.

 

[AcronymAllergy]

I think his point was that these are high base rate behaviors/traits in the general population, not to mention individuals with ANY psychiatric comorbidity (which is probably why they are scheduled with you in the first place), and the diagnostic process for AD/HD is troublesome/tricky and not fitting with the typical time alloted for most psychiatrists in the outpatient setting.

The situation your described could be attributed to literally scores of other factors and their combined effect. This is why this disorder is so tenuous (and frustrating) to diagnose in practice.

Agreed. We frequently saw people in our college psych center who were coming for evaluation thinking they had ADHD or some form of LD because they were doing more poorly than they were used to in their classes. In most cases, it was due to their having skated through school without needing to study, but now being away from home with newfound freedom, needing to nearly-independently manage their own schedules (and lives) for the first time, and also needing to essentially learn how to study. They didn't have ADHD, they just had poor study skills, lackluster motivation (at times), and/or bad time management.

We certainly don't want to ignore the possibility of a missed childhood ADHD diagnosis finally showing up in college, but we also don't want to label all folks who have some trouble adjusting to the demands and rigor of college (compared to most primary/secondary schooling) as ADHD or learning disorder.

 

[WingedOx]

On a positive note, I had a patient come with a standard ADHD-looking case. I actually figured he was legit. Youngish adult patient, pattern seemed consistent with a guy who just never got diagnosed. Sent him to neuropsych but almost didn't because he seemed straightforward. Testing came back negative, and I reviewed it with him, and his response we "oh man, that's GREAT! I'm so glad I don't need meds! I thought I did horrible on that test". He was happy that he just needed to use better cognitive and environmental tweaks to improve his work performance.

It's kind of amazing yet a little sad how rare a response like that is.

 

[thoffen]

CBT for procrastination is a thing. If you don't care to provide that intervention, find a good psychologist and refer.

I mean, if you have the time.

 

[erg923]

I mean, if you have the time.

I'll learn that tomorrow....

 

[hypoman]

Not a big fan of ADHD myself. I just can’t help but think in a few years down the line we’re going to be like “wtf were we thinking giving meth to children?”... seriously amphetamines are practically crack and make you feel like a god. Not good at all for your physiologic health. They have their place but imo are waaaay over prescribed.