Testing for ADHD: Simple Psych Evaluation? Or Complete Pysch Battery?

This post is long, so out of kindness to readers with ADD, I've summarized it at the end with nice bold bullet points.  Also, I'm not a doctor and I'm not a psychologist, so you know this isn't medical advice, right?  

Good.

I'm glad to be in correspondence with Mo over at Milligrams Blog.  We've been through a lot of the same shit.  And lately he's been raising some very good questions about ADHD -- what it's like, how it's treated, and the latest question, how it's diagnosed.

He thinks that a lot of his symptoms could be explained by ADHD, and recently asked his doctor about getting an evaluation and medication for the condition.  In a comment to my earlier post, he said that his doctor, who's an addiction specialist among other things, wants him to get a full neuropsychological evaluation before putting him on potentially addictive meds for ADD.  The psych eval will take several hours.  His insurance company won't cover it.  And he's never heard of this one before.

I'd always read that ADD is diagnosed by a psychiatrist carefully interviewing the patient, their family members, and looking at records like old report cards in order to establish that the symptoms have been present since childhood.  Symptoms must also be present in all areas of a patient's life -- education, work, home, leisure, interpersonal relationships ... you name it.

I'd also read that neuropsych evals were considered problematic for diagnosing adult ADHD, and were not often done.  Certainly there are plenty of folks on ADD Forums who were diagnosed through psychiatrist interviews alone.

I was surprised to learn that (according to Wikipedia and WebMD anyway) neuropsych batteries are supposed to be part of the adult ADD diagnosis. 

The difficulty with this is that, as I mentioned, these tests require the patient to pay for several hours of a clinical psychologist's time out-of-pocket.  Most insurance companies won't cover them.  I had mine done back in college, I went into debt to pay for it.

The reason I needed to get a neuropsych eval was that I was being tested for a specific learning disability, dyscalculia, in addition to ADD.  I was also seeking disability accommodations from my college, and these required extensive documentation.  I may or may not have been able to get an ADD diagnosis from a doctor alone.

The phrase "neuropsychological evaluation" kind of sounds like it involves brain scans and such, but it doesn't.  It's a series of cognitive tests administered by a clinical psychologist.  These psychologists have PhDs in clinical psych; they are "doctors" in the sense that they have a doctorate, but they are not MDs so they can't prescribe meds.  MDs, likewise, aren't qualified to administer and score neuropsych evals. 

The psychologist scores the test to see the results from each subtest, which are then combines somehow to score the test overall.  The results for are expressed by percentile.  I guess a "normal" person's results will mostly cluster within a few percentiles, possibly within a single standard deviation (which I think means that they're in the same general area on a bell curve).  Wrightslaw, which is a site devoted to special education law, probably has a better explanation than I can provide.

In my case, the psychologist diagnosed ADD based on several things.  There was a huge difference between my "verbal" and my "performance" results (two standard deviations, which I guess is a lot).  There was a lot of "intra-test scatter", meaning that my results in various parts of the test were variable and inconsistent.  The psychologist also noted that my attention wandered during the test.

At the time my relationship with my father was incredibly strained, and I didn't feel comfortable going home to try and find my old report cards, nor did I feel comfortable having the psychologist discuss the matter with my parents.  The fact that my diagnosis was made pretty much based on the test is pretty unusual.

I suspect that the doctors that want the neuropsych battery, like Mo's pdoc, are wary of prescribing potentially addictive meds, or, in the case of new patients, are concerned about drug-seeking.  The symptoms of ADD are pretty easy to fake, and the patient can easily lie about their childhood and their overall performance at school, work, and life in general. 

The test, however, is harder to fake.  On the other hand, it's not necessarily considered to be conclusive -- for one thing, the test is performed one-on-one in a distraction-free environment that pretty much isn't replicated elsewhere in life.  As you might imagine, a lot of people with ADHD will perform better in this situation, yielding a false negative.

To summarize:

• Testing for ADHD takes several hours with a highly trained professional.
• For this reason it is very expensive.
• Most insurance companies won't cover it.
• The test helps to rule out other conditions that mimic ADHD.
• Psychologists do some kind of mathemagic to score each subtest and compile these into a "verbal" and a "performance" score.
• This may indicate ADD (as long as other criteria are met -- impairment in every area of life, and a history of inattention going back to childhood).
• Intratest scatter also may indicate ADHD.
• The test results, along with patient interviews, interviews with people close to the patient, and past and present under-performance in all aspects of the patient's life, will probably result in a diagnosis.

 However, I am not an expert, so take this with a grain of salt.