Thursday, January 6, 2011

To Test or Not to Test

From time to time I will hear that an individual "is being tested for ADHD" as though there were some objective diagnostic tool which allows certain identification of the underlying condition, in the sense that one may be "tested" for Lyme's disease.

In fact, there is no "test" for attention deficit hyperactivity disorder. Rather, ADHD is a clinical diagnosis made on the basis of
  • an interview,

  • history,

  • behavior observations,

  • review of pertinent medical records, and

  • collateral report (interview with a roommate, spouse, parent, or teacher).

Would that we had some objective "test"! Such wishful thinking was displayed several months ago, in an article in the New York Times which described a souped-up continuous performance test as a "biomarker for ADHD." An example of a true biomarker would be, for example, specific cerebrospinal fluid protein abnormalities in Alzheimer's disease. Or a positive dexamethasone suppression test in the case of clinical depression. The concept has been extended, in psychiatry, to include cognitive phenotypes in addition to "substances" like proteins.

In the case of, ADHD, however there is in fact no "biomarker." In fact, as a clinical entity ADHD is heterogeneous, with multiple genetic risk factors, multiple environmental risk factors, and a variable clinical presentation.

But how might a continuous performance test, or some other type of neuropsychological indicator, improve upon the interview and clinical history for determining the presence and functional impact of ADHD? Is it recommended to have a complete neuropsychological assessment?

One consideration is the patient's and family’s time. A neuropsychological evaluation requires a greater commitment of time than a briefer office consultation. A second consideration is the considerable expense of neuropsychological evaluation. We want to direct our resources -- time and money -- in the most helpful direction.

There are times when I've committed 8 or 10 hours to a formal neuropsychological evaluation, only to confirm what the client herself, or the client's parents, already know. And in retrospect I wondered if we might have spent those 8 to 10 billable hours in a different way? For example, patient education, spouse education and support, specific parent training, or ADHD coaching supports?

So how do we make this determination, To Test or Not to Test?

My perspective as a clinician who conducts this type of evaluation is threefold:

First, consider the complexity of the clinical presentation. If in addition to attention/focus/impulsivity are there are other clinical concerns? Such as depression or substance abuse or trauma related anxiety, or attachment disorder, or questions about general intellectual functioning? If so, then a complete neuropsychological evaluation may help "tease out" these factors so that we may speak to the specific functional impact of ADHD versus some of these other concerns.

A second consideration comes to mind when I think of the unsavory, but unforgettable, advice of a graduate program supervisor. When it comes to performing psychological testing, there's always the option of yet more evaluation. One more personality test, for example, or one more approach to verbal learning.

My supervisor’s advice was this: "It's like picking your nose - if you find something, where you going to do with it?" And likewise when we are considering a neuropsychological evaluation, we ask ourselves "what will we do with this information?" Practically speaking, how will these test scores facilitate services or treatment or predict success in an academic or vocational setting? What will you do with these data?

In my own practice, I do frequently conduct an abbreviated neuropsychological battery when the referral question is related to ADHD. This battery might include intellectual assessment, academic testing, evaluation of various aspects of memory and learning, as well as targeted evaluation of attention and concentration and focus.

The diagnostic impression of ADHD will not, however, be based on this testing. The diagnosis is offered, again, on the basis of history, clinical interview, and mental status exam.

And what test scores might provide me, over and above that clinical history, is a context. A way of understanding the client and his/her ADHD symptoms as it impacts academic or vocational settings. After confirming an ADHD diagnosis, I am sometimes asked whether or not this 17-year-old will be able to manage the demands of college or university. And I will make use of my test scores to better answer that question. Can a 17-year-old with ADHD reasonably expect college success? If the full scale IQ score is 100 or 110, my response might be “yes.” He can likely manage college coursework if he has a good academic and study skills supports, starts out with one or two college course is to "ease into" the demands of college coursework, lives at home with supportive family for a semester or so before making the transition to dormitory life and campus social life, and if he/she is really motivated and inspired by the particular course of study.

On the other hand, the 17-year-old with ADHD whose IQ score is 85 might find college coursework unmanageable. And the 17-year-old with full scale IQ score of 110, but reading achievement score in the low 80s may find college coursework overly demanding.

So, the additional neuropsychological data provides a context for understanding an individual client and making some useful recommendations her predictions.

A final concern, when it comes to the Test or Not question, is the extent to which a client actually needs my consultative input. Many parents, or adult patients, come to me fairly certain, they have some of the attentional and executive challenges associated with ADHD. And what they need from me is not a confirmation of this diagnostic label but, rather, some specific advice or direction or coaching type support.

In summary, the decision to pursue this type of evaluation will depend on:

  • the client's time and financial resources and how best to allocate those,

  • the complexity of the clinical presentation,

  • the practical "what will you do with this information" consideration, and

  • the extent to which you actually need diagnostic confirmation, or on the other hand could benefit from direction and advice.

To test or not to test? What's certain is that there's no need to to suffer the slings and arrows of outrageous fortune. Talk to your doctor or healthcare advisor about your concerns, and decide your next step. You can also contact me at David@DrNowell.com

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