Today's topic is about "Comprehensive Diagnostic Evaluations & Suspected ADHD" written by Clinical Neuropsychologist, Dr. Matt Landstrom. To learn more about Dr. Landstrom and his clinical interests click here.

Introduction

I often find myself explaining the importance of making sure there is a comprehensive evaluation before starting many treatments, even to clinicians with decades of experience in the mental health field.

Presenting Problems

I recently had an adolescent female patient (let’s call her “Rachel”) come to me who had previously described slower learning and difficulties related to Attention Deficit Hyperactivity Disorder (ADHD) to her therapist. Rachel had already been referred to another provider for an ADHD evaluation, though after she performed well on just one common computerized ADHD test, she was told she likely did not have ADHD. When this result was shared with her therapist, her therapist pointed out that there are false negatives on tests, and they decided to send Rachel to a psychiatrist for stimulant ADHD medication anyways.

On that medication, Rachel reported brief improvement, but she quickly noticed she was having the same problems at school. So, she reported persisting symptoms to her therapist and psychiatrist, and her dose was increased. Again, she felt like she saw improvement, but soon realized her same symptoms had persisted.

Again, her dose was increased, but she still struggled, and this pattern repeated for many months. Eventually, she was prescribed the highest dose of her stimulant medication to be taken 3 times per day, and now was not able to sleep and came in with a whole host of newly developed anxieties!

Diagnostic Clarity

The family switched psychiatrists and Rachel was immediately referred to me for a comprehensive evaluation, which revealed significant working memory issues without inattention or impulsivity problems.

I was able to explain to the family that working memory deficiencies can look and feel like the symptoms of “classic” ADHD, but unfortunately are a different issue and are not as likely to be effectively treated with stimulant medication. Alternatives options were provided and she was able to function much better going forward, though she now had a number of anxiety-related problems that would have to be addressed as well.

Conclusion

The reality is that everyone will feel like they benefit from stimulant medications for a bit, which is why we cannot simply prescribe ADHD medications and “see if they work” to diagnose. Also, by only telling Rachel she didn’t have ADHD without providing her and her therapist an explanation for those symptoms, they were only able to make guesses, which led to these terrible results.

Only through comprehensive, yet judicious, evaluations can we look at the big picture. It is situations like these that led to our treatment philosophy at the Landstrom Center; “test first so there are no questions later!”