Considering refusing ADHD evaluations

[u/KatarinaAndLucy]

I see patients aged 14+ at an outpatient FQHC primary care clinic am really considering declining intakes that are purely ADHD assessments for patients who are aged 19+. Out of the 16 intakes I have done so far for the week, 11 were adult adhd and it is exhausting.

Nobody else at my clinic has had a refusal for certain dx… Has anyone else refused adhd intakes? What did that look like for you?

Why am I over here missing inpatient SPMI, that is crazy 😭

UPDATE for confusion: I am a psych NP with years of experience and I work in a PCP office because the county does not have funding for more psychiatry clinics. Medicaid patients cannot go outside of the county for psych care per Medicaid rules so they have to see a PMHNP at a PCP clinic for “consulting.” In rural America it is called “integrative care”. Medicaid does not pay for neuropsych testing so patients don’t have that option either.

[u/I_am_Nobody_Special]

Several psychiatrists in my area refer them to my practice for a full psych eval when they suspect the patient doesn't have it. We have no problem being the bad guy and telling them they don't have ADHD.

And we've got some 1-star reviews to prove it! 😂

[u/I_am_Nobody_Special → u/[deleted]]

Testing isn't necessary, but it can help identify specific areas of need and can also sniff out malingering. The one thing testing can't always do is tell us why the person has the deficits.

But no matter what the testing shows, if there isn't a childhood history of symptoms, I don't diagnose it.

[u/BurdenOfPerformance → u/I_am_Nobody_Special]

Correct, but the patient can come to a psychologist for neuropsych testing without a psychiatrist referral also. I've never had a psychologist refer me to a psychiatrist. Which is a rather concerning issue if neuropsych test can produce sizeable false negatives. The other problem is that some people go through physical abuse and neglect and so if they do exhibit symptoms of ADD or ADHD its massively confounded by an unstructured household. This also blurs the lines of when it's ADD/ADHD or not.

[u/I_am_Nobody_Special → u/BurdenOfPerformance]

Yes that's why I said that testing may identify the cognitive deficits, but it doesn't tell us why they have those deficits.

[u/nothsadent → u/BurdenOfPerformance]

I wouldn’t dismiss unstructured households so easily. There are reasons why a household lacks structure, and undiagnosed ADHD in a parent can be a significant contributing factor.

[u/BurdenOfPerformance → u/nothsadent]

Yes you’re right too, but this is more so for abuse.

[u/DreamWorldDomination → u/I_am_Nobody_Special]

What kind of testing are we looking at ? And in your opinion, what would be the best way of getting a neuropsych evaluation for such cases?

[u/I_am_Nobody_Special → u/DreamWorldDomination]

I don't do a lot of these, but I usually give a broad self report measure like the PAI (similar to MMPI), norm-referenced ADHD rating scales, and the WURS which assesses childhood symptoms (not the most robust instrument though).

I will give the CPT-3 and sometimes the D-KEFS. I rarely give an IQ test, but that can be helpful too.

Collateral info is also important, and the psychologist will gather that.

If I were you, I'd make contact with a psychologist or two who do these evaluations and then just start referring to them.

I think psychiatrists like getting the psych eval because then they don't have to do all the collateral contacts and records requests. Insurance pays us by the hour to do it.

[u/Hypername1st → u/I_am_Nobody_Special]

No CAARS?

[u/I_am_Nobody_Special → u/Hypername1st]

Yeah I typically give the CAARS as well.

[u/Psychiatry-ModTeam → u/[deleted]]

Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.

[u/sparklemoar]

A LOT of us currently employed in outpatient settings talk amongst ourselves about doing the same once we go private. Say what you will about it, but these evals and certain frequent behaviors these patients are prone to are emotionally exhausting for a lot of folks. If only I had a dollar for every time I told someone ADHD doesn’t randomly appear when you’re 48, then they changed their story and said oh no that’s not what I mean, I was actually like this since I was 3. Doing this same unproductive dance 4 times per day is not a good use of the limited resource that is psychiatrists’ time in a society where there are massive mental health accessibility issues.

[u/Morth9 → u/sparklemoar]

Or better yet, they have learned beforehand (from their online 'research' or PCP appointment) that ADHD does not randomly start in adulthood and adjust the timeline accordingly. I have literally had intakes in which the adult patient insists that it has been a lifelong pattern with clear childhood impairment--when I have in hand the PCP's referral note in which the pt had reported onset in the past year or two.

[u/sparklemoar → u/Morth9]

I was going to also include something about that alternative scenario in my comment but figured it best not to rant too much and sound too burnt out 😅

They really think I don't know they're all reading the same online guide on how to force a psychiatrist to diagnose you with ADHD lol. How coincidental, you're my 5th patient of the day whose report cards always mentioned that you were too talkative and who always had to sit beside the teacher's desk because you disrupted the other kids too much.

[u/steventhevegan → u/sparklemoar]

I know anecdotes from regular folks aren’t allowed, but I’m hoping at least a thank you is?

Been diagnosed for over 30 years. Hearing a practitioner say these things out loud is actually extremely validating. Been feeling very frustrated with people cosplaying a thing that I very much wish I did not have.

[u/SearchAtlantis → u/steventhevegan]

Bruh SAME.

[u/steventhevegan → u/SearchAtlantis]

There needs to be a subreddit or something for us because the current ones are completely overtaken. Where are my nurses-station-at-lunchtime buds at? We still having to stay late to finish our work? Did the weird biofeedback experiments also not work for y’all? Where’d we all end up?! I have so many questions and all I can find is “wow speed feels AMAZING” or “this TikTok about leaving laundry in the washing machine is so relatable LOL” or whining they could have been somebody if only someone had listened… despite being an honors student.

I’m tired of this grandpa

[u/eternalconfusi0nn → u/sparklemoar]

What if they showed the report cards? I dont think everyone would be lying no?

[u/sparklemoar → u/eternalconfusi0nn]

I always ask, and not a single person has been able to provide them. I’ve started requesting that they contact the school district to see if anything is on file, and everyone complains about being asked to try that.

[u/SkywalkerG79 → u/sparklemoar]

Only 4 times a day? Lucky ha. Agreed with all, it’s exhausting.

[u/sparklemoar → u/SkywalkerG79]

Haha I was just thinking of the new evals for that day. Include follow ups in there, and some days are substantially more 🫠

[u/I_am_Nobody_Special → u/sparklemoar]

B...b...but ADHD presents so differently in women! Because women "mask"! I know I had a high school GPA of 7.99, but I was masking! You're just sexist because you don't know that!

Ugh.

[u/sparklemoar → u/I_am_Nobody_Special]

Ultimate get out of jail free card lol. It pisses me off as a woman because there's actually truth to the idea that many women with true ADHD fly under the radar as kids because they don't piss adults off as much.

But now it's even harder for them to be taken seriously in adulthood because of people touting the "masking" card as the ultimate way to back your psychiatrist into a corner.

[u/I_am_Nobody_Special → u/sparklemoar]

Agreed, and I'm a woman too. For some reason the word "mask" gets under my skin. I think I need a vacation.

[u/Upstairs_Fuel6349 → u/I_am_Nobody_Special]

I mean...we all mask. It's completely normal to change how you behave in certain situations. I'm fairly introverted but will suck it up to make small talk with a patient. It's generally considered abnormal when you can't mask. But not every struggle or quirk needs to be pathological. If I was introverted to the point that I couldn't speak with patients -- now maybe I have some social anxiety disorder stuff going on.

I'm not sure if it's partially social media painting unrealistic pictures of how people function? I just hate how everything is a diagnosis.

[u/I_am_Nobody_Special → u/Upstairs_Fuel6349]

You're totally right. Not every absent-minded person has ADHD, and not every socially weird person has autism.

We've all hidden symptoms and quirks by "masking", like stifling shyness while mingling at a bar, or smiling and pretending to enjoy a conversation with an annoying neighbor.

We act differently depending on whether we're at a concert or a funeral. We talk differently to our spouse than our boss, or the cashier at the store.

None of this is mental illness.

[u/KaiserKid85 → u/Upstairs_Fuel6349]

It's social media. I blame mental health tik tok. There are some educated content out there that is helpful and aimed at strategies... But the vast majority is here are ways to know you have adhd

[u/folderol_fox → u/KaiserKid85]

Ways to know you have ADHD or autism. Pisses me off to no end that there are folks out there who are struggling or feel in some way ‘other’ and social media diagnoses them with something trendy and then they don’t end up getting the actual treatment they deserve for whatever it is that’s really going on with them.

[u/folderol_fox → u/Upstairs_Fuel6349]

This. Masking is literally what human beings were evolved to do as social animals. We all have to keep it inside a little, babie.

[u/sparklemoar → u/I_am_Nobody_Special]

I think another reason the term's use as a "gotcha" tactic pisses me off is that it COULD be a useful way, for therapy patients for example, to explain having to hide one's true struggles to get by in certain settings.

Instead, it's been reduced to a meaningless, unfalsifiable pop culture term.

[u/Hypername1st → u/I_am_Nobody_Special]

Great! Adequate compensatory strategies leading to lack of reduction in everyday functioning. Literally excludes ADHD.

[u/I_am_Nobody_Special → u/Hypername1st]

Bingo. No impairment.

[u/steventhevegan → u/I_am_Nobody_Special]

Legitimate question as a very long time ADHD patient: do these people honestly believe that we just… chose not to mask and chose to experience the shame of having ADD in the 90’s - especially as a young girl? Like do they not think if we could have, we absolutely would have compensated enough to have that kind of functionality? Like that wasn’t the literal goal everyone was desperately trying to get us to meet?

The mental gymnastics I see with newly diagnosed people completely ignores the reality of having ADHD, but somehow saying that out loud is ableism. And yet, despite still never wanting to take my meds but doing it anyway so I stay employed, there’s a regular shortage I have to figure out how to plan for enough because they’ve strained the supply chain themselves. Hm.

It’s tiresome. I can’t imagine what it must be like for y’all. We’re exhausting enough as patients with how we’re always late to our appointments or needing a million PAs or generally forgetting or being obstinate about taking our meds, but now you have them too. Yikes.

(Edit: if this is too anecdotal, my bad, yall just struck at a thing that I’ve been doing my best to stay quiet about)

[u/I_am_Nobody_Special → u/steventhevegan]

So I have ADHD as well, diagnosed in adulthood. I'm also a woman. I was a very high-IQ kid earning Bs and Cs. I was daydreamy, got in trouble for talking and not being on task, couldn't organize my stuff, etc. Barely got accepted into college.

ADHD diagnostic criteria requires that several of the criterion A symptoms were present prior to age 12. I see a lot of adults who have no evidence of symptoms in childhood. They graduated with a 4.0 and had zero behavioral issues.

If you legit have ADHD, symptoms would have been evident as a kid. If you say you had symptoms but "masked" them and essentially functioned normally, you don't have ADHD.

[u/eternalconfusi0nn → u/I_am_Nobody_Special]

Having high grades doesnt really exclude ADHD, someone with high intelligence can get good scores without even trying, it happens, or do you not believe that either?
Or am i misunderstanding something here? Good grades = no adhd?

[u/I_am_Nobody_Special → u/steventhevegan]

So I have ADHD as well, diagnosed in adulthood. I'm also a woman. I was a very high-IQ kid earning Bs and Cs. I was daydreamy, got in trouble for talking and not being on task, couldn't organize my stuff, etc. Barely got accepted into college.

ADHD diagnostic criteria requires that several of the criterion A symptoms were present prior to age 12. I see a lot of adults who have no evidence of symptoms in childhood. They graduated with a 4.0 and had zero behavioral issues.

If you legit have ADHD, symptoms would have been evident as a kid. If you say you had symptoms but "masked" them and essentially functioned normally, you don't have ADHD.

[u/eternalconfusi0nn → u/I_am_Nobody_Special]

Good grades dont exclude ADHD, some people get good grades without even trying, being bad at school lessons is not the only symptom of ADHD, I dont understand your point.

[u/HanSingular → u/sparklemoar]

 If only I had a dollar for every time I told someone ADHD doesn’t randomly appear when you’re 48

Recognition at 48 doesn't mean onset at 48. This kind of thinking is partly why adults born before 1980 are substantially under-represented in recorded ADHD diagnoses and treatments.

I get that there really is a huge influx of fakers, and you're here to vent, but watching ya'll seemingly gleefully talk about denying treatment to people because they're members of groups we know are being under-diagnosed makes me want to pull my hair out a little. Please, please use better pre-screening criteria than age and lack of childhood diagnoses.

[u/sparklemoar → u/HanSingular]

I’m talking about the people who initially report that these symptoms just started or started 2 years ago, i.e. a 50 year old who, when you ask when they first began having issues with task completion, inattentiveness, etc., says it started 2 years ago. Then when you provide psychoeducation regarding ADHD being a neurodevelopmental disorder, they say actually it started when I was 3.

There’s no glee involved for me. I’d love for clinical interview alone to be a sufficient tool for diagnosing ADHD like it is for most other mental health conditions. True ADHD is actually very rewarding to treat. Unfortunately, the current state of affairs has created a nightmare scenario for clinicians and patients alike, and it’s only human for clinicians to not want to spend every day of their working lives metaphorically banging their heads against a wall and emotionally drained. I’m not exaggerating when I say I have numerous colleagues who talk regularly about how they’re so miserable doing ADHD evals all day that they’re considering either starting a private practice in which they don’t treat ADHD at all or leaving clinical psychiatry all together. Life’s too short to keep doing something that you’re miserable doing for any reason, let alone because the internet says you’re a bad person for not wanting to keep doing it.

[u/HanSingular → u/sparklemoar]

I’m talking about the people who initially report that these symptoms just started or started 2 years ago, i.e. a 50 year old who, when you ask when they first began having issues with task completion, inattentiveness, etc., says it started 2 years ago

Fair enough. You didn't really say anything to indicate age discrimination. I was just in a mood and primed to read it that way because of a conversation I was having in another thread.

...they’re considering either starting a private practice in which they don’t treat ADHD.

Honestly, it sounds like that might be a better solution than either adopting arbitrary criteria for who you evaluate or evaluating everyone and burning out.

[u/police-ical → u/HanSingular]

To be quite frank, that kind of hair-trigger response is disappointingly common and really contributes to self-proclaimed ADHD advocates not being taken seriously. A clinician said something entirely accurate, and someone attacked them with an elementary objection that's familiar to literally everyone on this subreddit.

We have seen time and again that it does not matter how well one crafts a comment, someone will come out of the woodwork to argue that any effort at accurate diagnosis is unacceptable and discriminatory because it might theoretically exclude a rare edge case.

[u/sparklemoar → u/HanSingular]

I promise the internet will complain just as much once psychiatrists begin opting out of ADHD treatment all together as it currently does about psychiatrists having criteria for whom they will evaluate/treat. So might as well just provide or not provide whatever services we want with our own licenses.

[u/Peachmoonlime → u/sparklemoar]

To be fair, this is not a psychiatrist

[u/theongreyjoy96]

Primary care? You could just refer out. Alternatively I’ve seen clinics post publicly about refusal to see ADHD assessments unless they’ve done neuropsych testing, clear documented histories of ADHD, etc.

[u/KatarinaAndLucy → u/theongreyjoy96]

I am a Pmhnp who works in primary care office for consultative psychiatry. It is a rural healthcare thing called integrative care. Our county doesn’t have funding for much care at the community psychiatric clinic and Medicaid patients are not allowed care outside of the county so they have to see primary care for psych, with me “consulting”.

[u/theongreyjoy96 → u/KatarinaAndLucy]

Ah I see, that's tough. I would certainly still see these patients as I would assume they have a chief complaint of inattention, impulsivity, etc. which can be symptoms of other psych disorders that you can treat. 9 times out of 10 they have cognitive symptoms that clearly started in adulthood that's due to some other cause like another primary psychiatric disorder, substance use, a medical condition like sleep apnea/hypothyroid, or even just a sedentary lifestyle.

On the day of the eval, the first thing I do is manage expectations. I'm up front with the patient that I may not be able to render a diagnosis of ADHD or even start treatment for it until I get to know them over the long term. This weeds out the stim-seekers, who often no show the next appointment, and sometimes I see on PDMP that they went elsewhere for adderall. That's fine - I'm not a drug dealer.

This leaves the patients genuinely looking for help. I subscribe pretty hard to ADHD as a neurodevelopmental disorder, so during the eval I'll look for the usual signs like symptoms starting around the age of 7, impairment in multiple settings, etc. If the patient has any trouble providing collateral or recalling the details of their childhood, I consider it a red flag that something other than ADHD is going on. Most often they don't have any of the classic s/s of ADHD, so I'm mostly looking for any alternative explanations and contributors to the patient's chief complaint.

At the end of the eval, my goal is to plant the idea in the patient's head that they're suffering from something other than ADHD without invalidating their concerns. Most often they associate "I can't concentrate" with ADHD, so I'll try to drive home that cognitive issues can be due to other disorders. For example if a patient reports depressive symptoms, I might explain that depression can present with inattention, etc.

This is just what I've learned from my experience with this population, which is by no means the standard, but it's been effective for me so far.

[u/Educational_Sir3198 → u/KatarinaAndLucy]

I don't manage with stimulants and this moves them on to greener pastures. I think it's horrible that Psychiatry has decided amphetamine based treatment is first line therapy, but if they want to see these patients and Rx that's fine with me

[u/crunk_crone]

PMHNP working with adults only via telehealth. ADHD inquiry intakes seem to come in waves and have recently been much higher with the start of the new academic year. It is very fatiguing and especially frustrating when patients say they have been referred by their therapist for an obvious anxiety or depressive disorder. I refuse to be bullied or pressured by admin to pump out stimulants to maintain metrics. I fantasize about declining these intakes but just use it as an opportunity to provide psycho education. It is disheartening how many patients appear visibly disappointed when sharing the clinical impression that their procrastination is best explained by avoidance secondary to anxiety and they are not “neurodivergent”.

[u/OaklandNotTheBay]

What would be your grounds for refusing? Just that you don't like it? Or that they're frivolous?

If you don't think they have ADHD then evaluate them and say that. I wouldn't refuse an intake just because I didn't like the subject matter.

[u/CompetitiveInhibitor → u/OaklandNotTheBay]

Saw a well respected attending collect two board complaints in a handful of months as he ran into this situation repeatedly.

[u/corsariolc → u/CompetitiveInhibitor]

I left a job because it was 80% stimulant management and new evals for ADHD/Autism. I completely get your frustration OP!
That said, I agree with the identity politics and belonging component, which sets you up for complaints from all levels. It's a fine needle to thread, for sure. I would say it's about having clear policy at the clinic level about an evaluation protocol, stimulant prescribing, and education that ADHD is a diagnosis of exclusion.

"Adult ADHD" is one of my hills to die on, but it's not a fight to pick alone in a healthcare system.

[u/more_business_juice_ → u/CompetitiveInhibitor]

The complaints were for not diagnosing people with ADHD?

[u/asdfgghk → u/more_business_juice_]

These would be throw out with prejudice. It’s not anything to worry about. If they don’t have it they don’t have it.

[u/CompetitiveInhibitor → u/asdfgghk]

That’s true but it’s an incredible nuisance. 

[u/InfiniteWalrus09 → u/asdfgghk]

While they get thrown out it is still time, anxiety and in some cases money. I had a frivolous board complaint that I still had to spend 2-3 hours addressing with my malpractice company, reviewing charts, writing a summary. It was thrown out very quickly- but the process cost me time, stress and it cost me $1000 with malpractice (you get a $ amount off for no use in a designated period of time).

[u/Averagebass → u/more_business_juice_]

Yes, they want a stimulant to lose weight and not be sleepy.

[u/New_Vegetable_3173 → u/Averagebass]

Does adhd meds make people not sleepy when used by people without adhd? I can take mine then have a nap 😂

[u/CompetitiveInhibitor → u/more_business_juice_]

Correct.

[u/Carlat_Fanatic → u/CompetitiveInhibitor]

I know a good amount of colleagues who stopped taking intakes related to ADHD or Autism for a few years now. IMO I think that due to these diagnoses commonly having such a strong identity politics component, it’s almost guaranteed that you will get complaints files against you if you take that approach.

I get both sides. Where I practice in outpatient psychiatry it’s almost a distribution of 80% of evals being requested for ADHD/Autism and almost 100% of CCs being “fatigue and executive dysfunction”.

[u/SporadicWanderer → u/Carlat_Fanatic]

I assess ASD in early childhood, where a diagnosis is necessary for certain services (ABA, state waiver, etc.)
Just curious, why do you think so many adults are requesting autism evaluations? I know some autistic advocates say it’s important for their own understanding and to validate their life experiences. But what tangible gain is there? Does it ever change medication choices in newly diagnosed adults? Psychotherapists can treat presenting concerns without the dx… many of these folks already have ADHD diagnoses and can request workplace accommodations with that… I guess I just don’t understand the reasons behind this trend.

[u/slaymaker1907 → u/SporadicWanderer]

Besides ADHD-esque accommodations, it could help stop coworkers from complaining about one not making good eye contact or not having enough variance in one’s tone of voice during things like preparing a presentation.

Or that lack of eye contact does not mean that one is necessarily lying or something.

So in general, just wanting more compassion from society at large for being different in ways that are very difficult to control.

It’s less common now given the heightened awareness about autism, but it definitely used to be a lot more common.

[u/I_am_Nobody_Special → u/SporadicWanderer]

ASD is a trendy diagnosis. People who feel like they never really fit in anywhere will latch onto autism like it's an exclusive club.

Then they will come to us to validate their new chosen identity. If we don't agree, we are the devil because they've already joined all the online autism communities and have been telling everyone they are on the spectrum.

Most of the time it's just some cluster B traits.

[u/Hypername1st → u/SporadicWanderer]

Claiming some form of AuDHD provides a wonderful justification for a lot of cluster B patients to never engage with actual therapy.

[u/sockfist → u/SporadicWanderer]

It's a way for BPD patients to abdicate responsibility for improving their lives via the slow, difficult, iterative improvements that come from sustained engagement in evidence-based psychotherapy.

[u/folderol_fox → u/sockfist]

The take we all wish we could say out loud 👏😣

[u/asdfgghk → u/Carlat_Fanatic]

What’s your suggestion? Be bullied into a diagnosis they don’t have which is fraud

[u/police-ical → u/CompetitiveInhibitor]

I've had a number of unhinged bad reviews for this situation though no board complaints yet. The bad reviews are occasionally helpful when hiring therapists, who can read between the lines and know they're interviewing at a real practice instead of a pill mill.

Personally, if I got a board complaint for not prescribing a controlled substance, I think I'd have it framed.

[u/MeasurementSlight381 → u/CompetitiveInhibitor]

For refusing intakes or for not giving people the diagnosis they wanted?

[u/CompetitiveInhibitor → u/MeasurementSlight381]

Not giving ADHD diagnoses.

[u/MeasurementSlight381 → u/CompetitiveInhibitor]

That's wild! I hope the board dismissed the complaints or ruled in favor of the psychiatrist. We shouldn't place a "missed" ADHD diagnosis on the same level as a missed SMI diagnosis.

[u/CompetitiveInhibitor → u/MeasurementSlight381]

I’m sure they dismissed them but what an absolute nightmare to deal with. 

[u/super_bigly → u/OaklandNotTheBay]

Cause it's freaking exhausting to spend a bunch of time on a real assessment, explaining to the patient why you don't think they have ADHD and then having a mad patient half the time who isn't going to followup....so then you have more availability for more ADHD evaluations lol.

OP you could always do what everyone else is doing and just start everyone on a stimulant who says they can't pay attention and they probably have a "missed ADHD diagnosis cause I'm a child of the 90s".

[u/Upstairs_Fuel6349 → u/super_bigly]

A lot of our meanest/nastiest patients are ones that the doc doesn't think has ADHD, too. There's something about being denied a stimulant that really brings out the biggest cluster b behavior in people.

[u/re-reminiscing → u/OaklandNotTheBay]

It is not that simple when declining to provide the ADHD* diagnosis frequently leads to arguments and unpleasantness, it’s a great recipe for burnout.

[u/zozoetc]

Used to have an outpt clinic as part of a university health system. So, so many college kids coming in for stimulants and very few who actually met criteria. My life got a lot better when I instructed my scheduler to tell people calling for appointments that I don’t prescribe stimulants. Didn’t get any pushback from management—not like there was a shortage of patients

[u/Narrenschifff]

Taking a clinic wide policy of SAYING that no stimulants will be prescribed unless there is a documented childhood history of ADHD diagnosed by a mental health professional, AND there is ongoing active work or school, can do a lot to reduce frivolous assessments and referrals. It does not mean that you can't break the stated policy and prescribe stimulants when they're clinically indicated... but, this relies on the clinic holding the line and clearly communicating these expectations.

[u/HanSingular → u/Narrenschifff]

 unless there is a documented childhood history of ADHD diagnosed by a mental health professional

I get that the high demand is causing burnout, but this is an excitedly arbitrary way to try and pre-filter for if you should do an evaluation or not. There's any number of reasons a kid with ADHD might not ever be evaluated. For one, black and hispanic kids are more likely to have their ADHD misdiagnosed as Oppositional Defiant Disorder. (edit: Girls are also less like likely to be diagnosed as children. Children from non-English-speaking or emergent-bilingual households are less likely to be diagnosed. Children with a high IQ are less likely to be diagnosed.)

Requiring "a documented childhood history of ADHD" is clearly going to create selection effects for ethnicity and SES status.

[u/Narrenschifff → u/HanSingular]

I gotta tell you, it's not the low SES and minority patients who are coming in with the ready-made idea that they have ADHD. Frankly, not creating some triage system is going to reduce availability of actual care to those underserved people you mention.

[u/HanSingular → u/Narrenschifff]

I understand that some kind of triage as needed, but, "a documented childhood history of ADHD diagnosed by a mental health professional, AND there is ongoing active work or school" are objectively terrible criteria to use.

If higher-SES patients are more likely to arrive with a ready-made ADHD narrative, requiring a childhood diagnosis by a mental-health professional and current work or school perversely favors those same patients, since they are more likely to have old records, prior specialty access, and be employed or in school.

Meanwhile, an adult who was never recognized as a child, or whose symptoms contributed to dropping out, or unemployment, would fail your filter before anyone examines the clinical evidence. A group can account for fewer self-referrals and still be disproportionately harmed by a gatekeeping rule.

There are other criterion-based approaches you could use instead.

[u/Narrenschifff → u/HanSingular]

I think you misunderstand the difference between what I am saying to say and what I am saying to do.

[u/MeasurementSlight381]

I would ask the higher ups at the FQHC if you can refer these patients. How much time are they giving you to assess these patients?

Personally, adult ADHD evals can take me at least 1-2 hours (sometimes split into 2 appointments), especially if the deficits aren't immediately obvious.

[u/Hypername1st → u/MeasurementSlight381]

1-2 hours is still not that much time, especially if you're gonna do 3rd party hx, go over school reports, interviews, screen for comorbidities/exclude other causes esp. PDs etc.

[u/MeasurementSlight381 → u/Hypername1st]

Correct. Sometimes it takes multiple visits.

[u/asuram21]

You’re PCP, just refer out.

[u/seeyourintentions]

My caution is that ADHD referrals may not want treatment for other conditions, but the evaluation may allow them to better understand what else they may be experiencing and then they can potentially choose help for that condition at a later point in their life.

Otherwise, seems reasonable to just have them referred to neuropsychology. You could still do a general evaluation and provide a rule out diagnosis for the neuropsychologist.

You could consider that since it takes a significant amount of time to fully evaluate ADHD, including collateral, that you either are able to schedule multiple scheduled visits to complete the evaluation or refer out.

You could try to just say no, and see how it goes.

Do you have any particular concerns for repercussions if you choose to refer them out? Any if you decide to tell who you need to tell that you decline to see these?

[u/sparklemoar → u/seeyourintentions]

I completely do not get how the obtaining collateral piece works in real life as a new attending. I know it's what the guidelines say we are supposed to do, but every time I've mentioned getting it from an adult patient, it's either been met with bewildered stares or, alternatively, them putting their spouse on camera (I'm all telehealth), who then proceeds to awkwardly say something like, "Um, yeah, she's not real good at getting the cleaning done around the house."

[u/No_Title9375 → u/sparklemoar]

“Let’s see your room right now” 

This is mostly a joke. I would die if any of my docs said let’s see how bad you are doing right now 

[u/I_am_Nobody_Special → u/sparklemoar]

I have seriously called adult patients' elderly parents to find out whether they had symptoms as a child.

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[u/police-ical → u/sparklemoar]

It's not that bad. You explain briefly what the guidelines say and why: This evaluation has three parts (interview, rating scales, informant report) and it's important to combine multiple sources of information. Many people have trouble remembering childhood details for a developmental diagnosis, talking to parents helps improve accuracy. Be clear that this is part of the normal full evaluation, and that it would not be appropriate to prescribe a controlled substance without completing a full evaluation. You then ask for a good person (ideally a parent or other childhood caregiver, older sibling or childhood friend can be OK in a pinch), get their number, and ask the patient to give that person a heads up. If they push back, that's their call, but it's also yours not to prescribe a controlled substance.

Cognitively-intact parents are never too old for a phone call. It's rarely more than 10 minutes. Kosher to charge insured patient a fee for doing this if not on the day of service.

[u/sparklemoar → u/police-ical]

I guess a lot of why it doesn’t seem feasible to me comes down to my current micromanagey employment situation. I don’t have the ability to charge patients outside of the visits the clinic bills for, and it’d in any event be virtually impossible to coordinate schedules and squeeze phone calls with multiple people’s parents in…somewhere? between the back to back appointments I’m slammed with every day. I’m not giving up my short lunch break or barely existent admin time on a daily basis.

[u/police-ical → u/sparklemoar]

If you're not allotted adequate time to complete these evals, you should decline to do them until it is carved out in your schedule, or schedule time with the patient present to do them.  Collateral is not an extra credit assignment, it's a core part of the diagnostic process. Other specialties don't just shrug off labs and imaging as too time-consuming.

You're asking about being a new attending, which means you're now in a new phase of your career where no one else but you will advocate for doing your job right. At times you may have to stand firm. If you fold to admin pressure now and accept having to do a subpar job, you will find it all but impossible to be a decent psychiatrist over the long term.

[u/Hypername1st → u/sparklemoar]

We do that all the time and clearly communicate that to the patients. Yes, bring your school reports, workplace assessments, and we have to contact a person who's known you since before puberty. It is what it is.

[u/Whack-a-med → u/sparklemoar]

Patients should be able to easily to get affidavits from teachers they haven't talked to in years, family members who have known them since they were a baby and school nurses or Pediatricians who will definitely remember what timmy was like 20 years ago.

[u/SaveScumPuppy → u/Whack-a-med]

I am always so impressed by the many users of this sub who claim to routinely contact the grade school teachers of adults in their 30s and 40s about whether they remember if that one kid from a few decades back struggled with their school assignments. That's true dedication, and a worthy use of a psychiatrist's limited time.

[u/Psychiatry-ModTeam → u/[deleted]]

Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.

[u/Hypername1st]

An adequate, lege artis, diagnostic evaluation of ADHD is time intensive and demanding if you wanna actually exclude commorbidities or other clinical entities causing the symptoms. Adult ADHD, as a neurodevelopmental disorder with onset in early childhood, shouldn't be #1 on the DDx.

Unless you wanna become a pill dispensary for controlled substances, demanding enough time for the evaluations is important.

Completely refusing it should only be on grounds of competence or lack thereof, I would otherwise focus on communicating, that this isn't something that will be necessarily diagnosed and certainly not in a single appointment.

[u/Ok-Tea-6718]

I think it would depend on your clinic/organization if they’re willing to start referring those intakes specifically to neuropsych testing before seeing you.
Just curious what part is exhausting for you? Obtaining collateral or setting boundaries on controlled substances?

[u/Terrible_Detective45 → u/Ok-Tea-6718]

Neuropsych is not indicated, empirically sound, or the standard of care in ADHD diff Dx.

[u/psychcrusader → u/Terrible_Detective45]

Thank you. If I have to explain one more time we don't "test" for ADHD, I'm going to scream. (Quietly. In my office.)

[u/Terrible_Detective45 → u/psychcrusader]

Same. It really makes you wonder about the quality of training some people received and/or if they are keeping up with the literature.

[u/psychcrusader → u/Terrible_Detective45]

Part of the problem for me is there is a well-regarded (heaven only knows why) institution in my community that loves to do full neuropsych batteries and diagnose everyone with autism and/or ADHD. (They also make the most absurd recommendations.) What they are really doing is making $$$.

[u/Anxious-Education703 → u/Ok-Tea-6718]

The vast majority of testing done during neuropsych evals is not appropriate for ADHD diagnosis and is neither specific nor sensitive for ADHD. Russell Barkley wrote a good article about how it is not useful: https://guilfordjournals.com/doi/10.1521/adhd.2019.27.2.1

This doesn't even begin to get into the fact that it usually requires a prior authorization (which in turn usually involves fighting with insurance). If you can find an examiner that even takes insurance in your area, it usually takes months to get an appointment and can easily take a day or more to complete a full neuropsych battery (wasting both patient and examiner time). The fact that it requires so many hoops to jump through often is going to exclude the very people who have legitimate ADHD. If there is evidence to suggest there may be a condition that mimics ADHD that needs to be ruled out, then sure, it's appropriate, but it is completely inappropriate for a standard ADHD diagnosis.

[u/vienibenmio → u/Ok-Tea-6718]

Neuropsych testing is not needed for routine ADHD diagnosis

[u/MeasurementSlight381 → u/Ok-Tea-6718]

I imagine primary care in an FQHC means 15 minute evals or something similarly absurd.

[u/Ok-Tea-6718 → u/MeasurementSlight381]

Ahh I missed the PCP part, makes sense

[u/xiphoid77]

I refuse to do them. I am not trained well enough in the assessment and I feel this assessment needs to be done by those more qualified. I also strongly believe it is way over diagnosed, especially in adults. My clinic does not prescribe any stimulant medication either or treat ADHD.

[u/folderol_fox]

I feel so f-ing lucky to be in inpatient consult-liaison in this day and age for this very reason. “Sorry, I don’t diagnose ADHD in the hospital” is such a glorious thing.

[u/KatarinaAndLucy → u/folderol_fox]

It is so bad out here that i am considering going back to working inpatient, so i just wanted to say yes keep that CL job if you can lol

[u/folderol_fox → u/KatarinaAndLucy]

Join the dark side!!!

[u/Psychiatry-ModTeam → u/[deleted]]

Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.

[u/Psychiatry-ModTeam → u/[deleted]]

Removed under rule #1. This is not a place to share experiences or anecdotes about your own experiences or those of your family, friends, or acquaintances.