SSSSSSSOOOOOOOO . . . . . . . . . . Where ya’ been, doc??????
So sorry for the hiatus . . . and this entry is not a promise of more to come. But I’m hopeful. I been big-time busy over the last year or so. Lots of challenges in the work sector . . . lots of challenges on the home front . . . life is just busy and full of surprises. So what has finally got me back to the keyboard? Being wrong. As in mis-diagnosing a few people. Now, I’m not confessing that I’m not a good doc. I am. But no matter how good you are, you always get pulled one way in a complicated case when you should go the other way. The ambiguity of psychiatric diagnosis does not make anything easy. Especially when there is a complicated mish-mosh of symptoms that easily fit into more than one diagnostic category. And, you ARE allowed to have more than one psychiatric diagnosis. But how can I be sure that a child who presents with ADHD symptoms . . . and anxiety, and depression, and a complicated home life, and a complicated school picture . . . actually has ADHD and that the “ADHD symptoms” are not just a result of the other stuff?????
One of the things that has kept me super busy is trying to integrate a new diagnostic system into my practice. The Quotient ADHD Testing System is not exactly new (been around for a few years), but it is relatively new in my practice area. It is the newest generation of CPT (continuous performance test) that have been used for years to aid in the diagnosis of ADHD. Years ago I used the TOVA test. It was quite innovative at the time, but, computers being what they were 15 years ago, you ended up with a long and complicated report that was difficult to interpret and difficult for parents to understand. The Quotient test uses the same sort of technology . . . PLUS. The PLUS here is the innovative inclusion of motion detection that allows for a highly accurate reading of physical head movement. Using that data along with the visual response data allows for a highly accurate read on what someone’s pattern of ADHD symptoms are like.
But for me, the most exciting . . . and scary . . . part of including this system into my practice has been identifying those patients who I thought had ADHD . . . but have “normal” range Quotient tests. This is a problem. The Quotient test can, with no other information, predict with about 80% accuracy if a patient has an ADHD spectrum issue. For those of you who slept through statistics class, that is called the “positive predictive value”, or PPV. Having a PPV of 80% is really good for a psychological test. Especially one that can be given in 15-20 minutes. There are a lot of reasons why someone can LOOK like they have ADHD when they do not (hence, the risk of misdiagnosis). More importantly for today’s lesson, however, is the “negative predictive value” or NPV. This is the likelihood that a NEGATIVE test (ie, one that does not show the characteristics of ADHD . . . a ‘normal’ test) accurately predicts that someone does not have an ADHD diagnosis. The NPV of the Quotient test is 95%. That is extraordinarily high. That means if I take a kid off the street and give him a Quotient test and it comes up in the normal range, I can say (with no other info available) that I am 95% certain that that person does not have ADHD. Be impressed. In the world of psychometrics, that is almost unheard of.
So, what does that have to do with anything . . .
Suddenly, I am running the Quotient test on my patients and finding that some of them who I have been treating as ADHD for some time fall in the non-ADHD response pattern on the test. YIKES?????? These kids have been on a wide variety of medicine . . . Adderall, Concerta, Vyvanse, Ritalin, etc. Now all you out there know that I don’t think that any of these medicines are evil or bad. They are a great tool to address a difficult problem. But, what if I got the problem wrong? What if something other than ADHD is going on? This means that I have to dig deeper into these kid’s lives and look for other issues. In some of these kids the issues are obvious, and treating what looked like ADHD was a simple part of a complicated treatment regimen. For some, the answer is a bit more obscure. I got some work to do. But, thanks to the Quotient ADHD Testing System, I can, with reasonable confidence, allow them to avoid exposure to stimulant medicine and help them get to the core of their issues with focus and concentration. Without the fall-back of an ADHD diagnosis (and ADHD medicine), both kids and parents must confront those other issues that are driving the inability to focus/concentrate and inhibit impulsive actions. Double YIKES!!
So far, I have picked up quite a few kids that have been on stimulant medicine for years and have been able to taper them off their stimulants. A few have gone back on because they began to do so poorly. I have to work with them to try to figure out why the stimulants are so important to their overall success. I will be trying to get these kids off stimulants in the future. Most have been able to get off their stimulants and have done ok. I have some stories that I will be sharing on this site in future entries. Stay tuned . . . I’ll be right back!!
For more information on the Quotient ADHD Testing System, you can go to my website (www.philmontguidance.com) and take a look at the video (I was on TV!!!). You can also go to the Quotient website for more information.
www.biobdx.com/
–Dan Hartman, MD
PS: Glad to be back
