Approach to disparate behavioral assessments

[aim-agm]

What's the approach when different evaluators give different results on behavioral assessments (e.g. Conner scales)? I've not had much luck finding guidance via literature search.

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[WisNeuro]

Just self-report instruments? Or also objective cognitive instruments?

 

[aim-agm]

Just self-report instruments? Or also objective cognitive instruments?

Just self reports. The context is screening for referral from PCP

 

[WisNeuro]

Kind of depends on what norms they using to interpret the findings. Manual or supplementary?

 

[aim-agm]

Kind of depends on what norms they using to interpret the findings. Manual or supplementary?

Most frequently screening being done at the site is Conner's scale (CTRS/CPRS). They describe their norms as "Sex-specific, age-stratified norms based on a large, nationally representative sample."
What do you mean by manual/supplementary?

 

[WisNeuro]

In most assessments, there are the manual norms. The tables at the back of the manual that comes with the test. Unfortunately, some of these manual norms suck, and even though they say "nationally representative sample," the cell sizes are abysmally small. So, there are some instruments that have better norms from coordinated groups (e.g., Heaton norms for some measures). I list where my norms came from so another assessment person will know how I came to my conclusions.

Best bet may be to contact the provider who gave the conclusion and ask for clarification due to discrepant findings.

 

[aim-agm]

In most assessments, there are the manual norms. The tables at the back of the manual that comes with the test. Unfortunately, some of these manual norms suck, and even though they say "nationally representative sample," the cell sizes are abysmally small. So, there are some instruments that have better norms from coordinated groups (e.g., Heaton norms for some measures). I list where my norms came from so another assessment person will know how I came to my conclusions.

Best bet may be to contact the provider who gave the conclusion and ask for clarification due to discrepant findings.

So if the assessment returns significant differences between observers/evaluators (e.g. one parent vs. the other, parents vs. teachers), look into why that might be the case and don't rely on the assessment until there is a reasonable explanation?

 

[WisNeuro]

Ah, I assumed that you were saying that different clinical providers had given different interpretations, not that different raters returned different outcomes. In an ADHD assessment, the self and other-reports are only a small part of the picture. Clinical history and such are the bigger part. I'd just see if I could get them formally assessed.

 

[SeniorWrangler]

This might (might not) be a clue that it's not ADHD, it's context-specific behavior issues. A kid who is very bored in their classes can look severely ADHD to the teacher.

 

[singasongofjoy]

Disparate results on behavioral assessments can be just as informative as congruent reports. As mentioned above, a kid might have more issues in class if they are bored (e.g., if they already know the material, or on the other hand, if they are confused and not able to follow along due to learning issues, ID, vision or hearing problems-- not my client but I know a kid who had quite different reports from school and home, turns out he had amblyopia and schoolwork was frustrating the heck out of him). Or, last year I had a streak of having great reports from school and parents were reporting behavioral issues; found out home life was quite chaotic/unstable, parenting very inconsistent, etc. etc. Or, in one case, a mom who was really over-invested in her child having an ASD and/or ADHD diagnosis when one clearly was not warranted (though, unsurprisingly given their dynamic, he was a super anxious kid-- mom, on the other hand, had Axis 2 written all over her). Sometimes parents can have quite different reports because they have different expectations of what is typical vs atypical behavior for the kid's age or developmental level, or one is the one who typically gives demands/discipline and the other parent is less involved in those activities. Like WisNeuro said, refer for further assessment.

 

[aim-agm]

So should a PCP treat the behavioral screenings as a screen (i.e. value sensitivity over specificity) and refer even if something looks wonky with the results? Or should they seek context when different teachers/parents are giving different results and then use best judgement?

Ah, I assumed that you were saying that different clinical providers had given different interpretations, not that different raters returned different outcomes.

Thanks for your help! My apologies for not being clearer.

 

[WisNeuro]

IME, the PCP really doesn't have the time to properly do this evaluation. First you have to rule out any neurodevelopmental, learning disorders, and/or psychiatric disorders. If those are there, it doesn't mean it's not that and ADHD as many of them are comorbid and have similar symptom presentations. After that, you need a fairly comprehensive interview and collateral data from parents and multiple teachers. At best, you can offer a provisional diagnosis. Unfortunately, far too often kids are given a diagnosis based of a questionnaire or 2 minute conversation with a parent by their PCP. Don't be that PCP. Unfortunately, most insurance companies won't reimburse for ADHD/LD testing, so the kid will need to get it through school, if available, or pay out of pocket.

 

[Shikima]

IME, the PCP really doesn't have the time to properly do this evaluation. First you have to rule out any neurodevelopmental, learning disorders, and/or psychiatric disorders. If those are there, it doesn't mean it's not that and ADHD as many of them are comorbid and have similar symptom presentations. After that, you need a fairly comprehensive interview and collateral data from parents and multiple teachers. At best, you can offer a provisional diagnosis. Unfortunately, far too often kids are given a diagnosis based of a questionnaire or 2 minute conversation with a parent by their PCP. Don't be that PCP. Unfortunately, most insurance companies won't reimburse for ADHD/LD testing, so the kid will need to get it through school, if available, or pay out of pocket.

A good anecdote to this point for me yesterday. Late teens shows up to clinic with mom to discuss problems with concentration. Found out that he has a long history of insufficient sleep, snoring, had tonsils taken out and never underwent a sleep study. There are some other elements related to mood which was briefly treated with SSRIs in the past. So I needed to create an educational care plan, sleep study and psychotherapy to address mood issues before jumping on the stims bandwagon.

 

[WisNeuro]

A good anecdote to this point for me yesterday. Late teens shows up to clinic with mom to discuss problems with concentration. Found out that he has a long history of insufficient sleep, snoring, had tonsils taken out and never underwent a sleep study. There are some other elements related to mood which was briefly treated with SSRIs in the past. So I needed to create an educational care plan, sleep study and psychotherapy to address mood issues before jumping on the stims bandwagon.

Exactly, treating those things is going to lead to an exponential increase in QOL. Far more than the jolt that anyone would get from stimulants, and without that pesky added cardiac event risk.

 

[aim-agm]

IME, the PCP really doesn't have the time to properly do this evaluation. First you have to rule out any neurodevelopmental, learning disorders, and/or psychiatric disorders. If those are there, it doesn't mean it's not that and ADHD as many of them are comorbid and have similar symptom presentations. After that, you need a fairly comprehensive interview and collateral data from parents and multiple teachers. At best, you can offer a provisional diagnosis. Unfortunately, far too often kids are given a diagnosis based of a questionnaire or 2 minute conversation with a parent by their PCP. Don't be that PCP. Unfortunately, most insurance companies won't reimburse for ADHD/LD testing, so the kid will need to get it through school, if available, or pay out of pocket.

Thanks! I'm planning to go into psychiatry and, given my interest, my Peds preceptor asked me to look into how to approach these situations.

Tangentially, do you believe Neurology can adequately evaluate/treat for these conditions? Given the location and insurance (often medicaid) for patients at the clinical site there aren't really other options (e.g. Child Psych is a 6-month waiting list at best).

 

[WisNeuro]

Neurology would be worse than a PCP to evaluate this. What's the psychology availability in this setting?

 

[aim-agm]

Neurology would be worse than a PCP to evaluate this. What's the psychology availability in this setting?

One behavioral psychologist for a medium-sized city and the surrounding counties

 

[singasongofjoy]

Yes, I'd say sensitivity over specificity, and include the scores with any referral. Learn how to coach parents in approaching school for an eval if they can't get it paid for otherwise (e.g., request should be made in writing after which school is supposed to make arrangements for ax within a certain time period). Plus any relevant additional medical f/u as Shikima mentioned above (e.g., sleep study) of course.

How common is it in your areas for PCPs/referring providers to also administer broader measures (e.g., the CBCL) at the same time as the Connors? Might help to get at least a bit of an idea of other things going on (e.g., anxiety can look like ADHD sx in some kids) to give pause to those providers that are so quick to jump to an ADHD dx based on a conners, and maybe extra incentive to refer. But I haven't seen use of the two types of measures concurrently all that often in our referrals.

 

[WisNeuro]

One behavioral psychologist for a medium-sized city and the surrounding counties

Really? That's shocking, and really too bad.

 

[aim-agm]

How common is it in your areas for PCPs/referring providers to also administer broader measures (e.g., the CBCL) at the same time as the Connors?

I don't know if that's done. If it's not I'll suggest it.

Really? That's shocking, and really too bad.

Ya

 

[PistolPete]

IME, the PCP really doesn't have the time to properly do this evaluation. First you have to rule out any neurodevelopmental, learning disorders, and/or psychiatric disorders. If those are there, it doesn't mean it's not that and ADHD as many of them are comorbid and have similar symptom presentations. After that, you need a fairly comprehensive interview and collateral data from parents and multiple teachers. At best, you can offer a provisional diagnosis. Unfortunately, far too often kids are given a diagnosis based of a questionnaire or 2 minute conversation with a parent by their PCP. Don't be that PCP. Unfortunately, most insurance companies won't reimburse for ADHD/LD testing, so the kid will need to get it through school, if available, or pay out of pocket.

Agreed. I see this all the time. Especially from FP and child neurologist. 15 minute visit = ADHD. Ugh.

 

[AcronymAllergy]

Agreed. I see this all the time. Especially from FP and child neurologist. 15 minute visit = ADHD. Ugh.

Ditto. And then I or the psychiatrists have to be the one(s) to tell them it's not ADHD, it's "just" their anxiety, poor sleep, alcohol use, etc. Which generally isn't nearly as well-received.

One of the psychiatrists I work with has said he just wants to get a huge poster on his wall that says "sleep" so he can point to it and say, "let's fix that before we treat anything else."

 

[smalltownpsych]

I am shocked that there is only one psychologist in a medium-sized city. Psychologists do tend to have the best skill set for helping parse out the various issues that could manifest as ADHD and often can provide the intervention when indicated. Sometimes the ongoing intervention will lead to increased diagnostic clarification as I keep seeing the kid week after week and more is revealed.

 

[Shikima]

Ditto. And then I or the psychiatrists have to be the one(s) to tell them it's not ADHD, it's "just" their anxiety, poor sleep, alcohol use, etc. Which generally isn't nearly as well-received.

One of the psychiatrists I work with has said he just wants to get a huge poster on his wall that says "sleep" so he can point to it and say, "let's fix that before we treat anything else."

Are we working in the same office? haha... no, really, it does sound like me.

 

[aim-agm]

I am shocked that there is only one psychologist in a medium-sized city. Psychologists do tend to have the best skill set for helping parse out the various issues that could manifest as ADHD and often can provide the intervention when indicated.

My apologies, you're right, I misunderstood what the physician said. Their not allowed by insurance to refer to a psychologist, but the psychiatrist waitlists are too long and there is only one Behavioral and Development Physician that the insurances of their patients will allow referral too. Instead, they have to refer to Neurology, who in turn can make an assessment and refer to social services, who in turn can bring in a psychologist and contact the schools. So these kids eventually can get actual care, just in an unnecessarily roundabout and lengthy way because of insurance hoops and rules.

 

[PistolPete]

Ditto. And then I or the psychiatrists have to be the one(s) to tell them it's not ADHD, it's "just" their anxiety, poor sleep, alcohol use, etc. Which generally isn't nearly as well-received.

One of the psychiatrists I work with has said he just wants to get a huge poster on his wall that says "sleep" so he can point to it and say, "let's fix that before we treat anything else."

One of my attendings used to hammer the following into the medical students and residents rotating on the inpatient unit: "Psychiatrists are above all the protectors of REM sleep." And I think he's very right (very wrong on several other things, but right on this!). He'd procede to discontinue all the benadryl/klonopin/xanax/valium that was being used for sleep and ordering sleep studies on almost everyone (and finding obstructive sleep apnea many, many times).

 

[splik]

One of my attendings used to hammer the following into the medical students and residents rotating on the inpatient unit: "Psychiatrists are above all the protectors of REM sleep." And I think he's very right (very wrong on several other things, but right on this!). He'd procede to discontinue all the benadryl/klonopin/xanax/valium that was being used for sleep and ordering sleep studies on almost everyone (and finding obstructive sleep apnea many, many times).

how did he feel about antidepressants then, since most of them suppress REM sleep?

 

[singasongofjoy]

My apologies, you're right, I misunderstood what the physician said. Their not allowed by insurance to refer to a psychologist, but the psychiatrist waitlists are too long and there is only one Behavioral and Development Physician that the insurances of their patients will allow referral too. Instead, they have to refer to Neurology, who in turn can make an assessment and refer to social services, who in turn can bring in a psychologist and contact the schools. So these kids eventually can get actual care, just in an unnecessarily roundabout and lengthy way because of insurance hoops and rules.

Wow, that sounds like a terrible process. And I worry about kids falling through the cracks when they just have to follow through with one or two referrals.

 

[Shikima]

how did he feel about antidepressants then, since most of them suppress REM sleep?

The reduction in REM and the REM latency could be considered academic in nature. We fully don't understand the ramifications in sleep architecture. Heck, we're still scoring in 30 second segments called Epochs and haven't developed a fluid means to score brain wave activity.

 

[PistolPete]

how did he feel about antidepressants then, since most of them suppress REM sleep?

I don't remember him ever saying anti-depressants affecting sleep architecture negatively. *shrug* I once talked about REM suppression with a sleep psychiatrist who told me that this is overblown, since many meds suppress REM with no clinical significance whatsoever, so this lends credence to what @Shikima points out: we don't really know all that much about sleep architecture.

 

[Shikima]

I don't remember him ever saying anti-depressants affecting sleep architecture negatively. *shrug* I once talked about REM suppression with a sleep psychiatrist who told me that this is overblown, since many meds suppress REM with no clinical significance whatsoever, so this lends credence to what @Shikima points out: we don't really know all that much about sleep architecture.

Thus it's academic. There is no information in which will be mind blowing in how we prescribe medications.

 

[smalltownpsych]

My apologies, you're right, I misunderstood what the physician said. Their not allowed by insurance to refer to a psychologist, but the psychiatrist waitlists are too long and there is only one Behavioral and Development Physician that the insurances of their patients will allow referral too. Instead, they have to refer to Neurology, who in turn can make an assessment and refer to social services, who in turn can bring in a psychologist and contact the schools. So these kids eventually can get actual care, just in an unnecessarily roundabout and lengthy way because of insurance hoops and rules.

No need to go through all of those hoops then when the first person seen can just write a script for methylphenidate and everyone will be happy.