ADHD - Eval or wait?

[mamaraby]

I suspect one of my kids might have some variant of ADHD. Originally, I had thought about having this kid evaluated now before they head to public school next year, hoping that it would set this child up for the greatest success in high school. Our ped agreed and gave us a referral. We have an appointment for next year which is the earliest we can get in.

However, I was looking at our health plan documents and it looks like unless the issue is a result of autism (it’s not), our health insurance will not pay for it the eval or any treatment related to it. Our school district does not offer these sorts of services to homeschoolers. So now I’m wondering, is it completely unwise to wait? My original plan had been to at least answer the question before going in with the idea that if there was a dx, we could shorten the wait time for any potential accomodations. Plus, then maybe we could work on some of the needed skills for the rest of this 8th grade year.  But if I wait? Then what would you do?

 

[PeterPan]

Well your ps is confused, because identifying disabilities is FEDERAL LAW, meaning they don't have a choice. What they do have a choice on is offering services, because that depends on your state law, etc. But no, just for getting the evals, you make the formal written request, they do it, federal law. If they don't, sue them and someone will be fired.

If you suspect SLDs, you should go ahead and do the evals. If you suspect ASD, you should go ahead and do the evals. If you suspect ADHD and want meds, you should go ahead and do the evals. If you suspect ADHD and everything you're doing is fine (you don't need the information to improve how you work together) and you don't need medication, then I don't see the point. The school will do nothing until they've observed him for a grading period, most likely. They won't care about your $$ evals but will probably say fine, we'll watch for a grading period and then refer if he has issues.

There's some logic to this, because some things that you might have as issues at home might already be worked out by the structures in school! They already have a LOT of structures and supports built in as the norm. Like if you say oh he needs to type, well they probably already do. If you say he needs EF supports, well they may already have a lot. If you say he gets bored and loses attention, well it might be different with changing classes every period and herd effect and daily vigorous PE. Sometimes people find their kids do better in school, just because it's really good at providing those structures. ADHD kids THRIVE on structure. Structure is the buzzword.

Ok, I'll just ask cuz your sig doesn't say. He's in 8th now? And you're thinking to enroll him right before high school when you suspect he's going to have issues and need supports? I would go ahead and enroll him. Just saying. Or partially enroll him this year, let them get those observations going. Stuff like ADHD is totally driven by the forms the teachers, etc. fill out. Unfortunately, we as homeschoolers often don't have those forms. So maybe you work with them and say hey can I partially enroll him for like art, PE, german, band, whatever, in the afternoons, get a dab going. Often for ADHD you're talking a 504. Let him go through the crunchy stuff THIS year, when it's not affecting his transcript. 

I haven't transferred in, but that's just my two cents. My dd has ADHD and uses her accommodations in college. I had the local ps do evals on her in high school to finish her paper trail for college (and save me money, whew), and they would have given her a 504. We bridged to college with DE. There just is some crunchiness, and there are ways to do that. SKLAR is your kind of super-thorough method of choice. My ADHD girl learned how to do tech on her own and put in stuff and kick butt, but if you actually want to teach it that's what you're looking for. 

He may find the social is as challenging as the academics and EF. I don't know him, so I'm not saying anything personal or dropping hints. I'm just saying reality. Like if you're making a hit list, you've got your EF stuff, sure, being proficient in typing, definitely, and whatever issues there are socially to come up to speed on. It's not something to be underestimated. The SocialThinking site has a ton of great books that you can filter by age and topic till you find things that seem to fit. Your library may have a lot of them. 

[Storygirl]

Is the appointment you are waiting on with a neuropsychologist? It usually is a long wait to get in for an appointment, and we were told the same thing by our NP, that insurance would not cover testing if the main issue suspected is ADHD.

Here is the thing -- you don' t need a NP to diagnose ADHD. You can have a psychologist evaluate him. Or a pediatric psychiatrist. And some pediatricians will even do it themselves (it seems that yours does not, but some do). The school can also screen for ADHD, though we found that they wanted to see the outside diagnosis, as well.

If he is starting school in ninth grade, I would have him evaluated now, but I would look for a cheaper and quicker option.

But I also kind of agree with PeterPan that starting school in 8th grade in order to get things sorted out before high school begins is not a bad option. I realize there may be good reasons that you want to wait. But the school is likely to want to have him under observation for awhile by their own teachers, so that they can gain teacher input, and if this happens during ninth grade, that first quarter or semester of struggling (we have to assume there will be struggling, or the school will not see a need to evaluate) will show up on the transcript.

You may know this, but the school evaluation process takes time. From the time of your request for evaluations, they have 30 days just to consider the request. Then 60 days to run the tests and decide if an IEP or 504 is warranted. Then, if an IEP is needed, another 30 days to write it.

Which means that even if you start this process on the first day of ninth grade, it can take three to four months to complete the evaluation process.

Since you are thinking to start in 9th grade, having a private diagnosis in hand ahead of time might make that process go a little quicker.

[mamaraby]

Yes, currently 8th grade. This summer we gave the option to go in at 8th so that he could play soccer on the public school team and make it easier to transition to the high school team since we knew from the coach how it works on that end. He really wanted to homeschool for 8th grade and wanted to wait until 9th. We’re honoring that.

Yes, neuropsych and my sis had suggested a psychiatric prescriber instead. I have to call around and see if I can figure out who locally can provide that option. There are a couple of other mental health practices in the area that might be an option so they’re on my list of places to call. I don’t know if we want meds. I’m not opposed, but I’m also not opposed to building skills to address it outside of meds. High on my list (not sure it’s high on anyone else’s list) is cutting back on careless errors and right now that means I sit with him and I work on keeping him focused so he dosn’t skip steps. And organization. And chunking to avoid becoming overwhelmed. Maybe it’s not as bad as I fear it is.

I know the district does allow kids to enroll for a couple of classes at the high school level. Not so sure they allow it for the middle school. I’ll have to call and see.

Dh thought it’s possible that the switch to the school might be smoother than we anticipate. This kid has had outside classes and other  kid group type learning experiences and we have not gotten complaints from teachers. We have worked on social thinking type things along the way since when he was in school for on year in second grade that was an issue - not so much now aside from hey a good friend might do x in this situation or dude, don’t butt in to other people’s conversations.

[Storygirl]

It sounds like you have good plan for when to start school!

We've had three of our kids go through NP testing. We were really glad that we did, for all three. Two have learning disabilities. The third, we were just trying to figure out what was causing some struggles. We had had other screenings first that had not given us enough answers, and when the hospital offered that we could have him tested by their NP, we jumped at it.

We learned a lot from that NP report, but the findings were a lot less significant than for our other two children, and I think that getting the NP testing was probably overkill. Not that I regret doing it -- I'm glad for the information it provided. But we likely could have gotten similar testing from a psychologist, sooner and for less money.

We were not testing him for ADHD specifically, but I think for a suspicion of ADHD (which seems to be what you are describing), you can accomplish the goal with less testing than a NP would do. I hope you can find someone who can get him in sooner.

Also, with a psychologist, you hopefully can find someone who can not only do the testing but will do follow up counseling with you and not just recommend meds. A psychiatrist is more likely to prescribe meds as a first response, so I'd look for a psychologist instead.

(You are probably aware, but if you did decide to try meds, you would need to go to a medical doctor, since the psychologist can't prescribe, but you can jump over that bridge when and if you get to it.)

[Storygirl]

Also, I think there is another reason to check for the ADHD now, rather than later. If your son is going to learn and apply new skills and become proficient enough to be able to do it for himself while in the classroom (without you at his shoulder), it's good to have time to practice those things.

Because in high school, the accommodations for ADHD are going to be more like --- take tests in a quiet room to reduce distractions. Unless he has a learning disability and an IEP, it's not likely for the teachers to chunk his work for him or give him more guidance or second chances to correct careless errors.

He's going to need to be able to do those things for himself.

And, depending on the severity, teachers may not see the need for those kind of things to warrant an evaluation, so a private evaluation is probably a good way to go.

Edited September 13, 2018 by Storygirl

[PeterPan]

4 hours ago, mamaraby said:

I don’t know if we want meds. I’m not opposed, but I’m also not opposed to building skills to address it outside of meds. High on my list (not sure it’s high on anyone else’s list) is cutting back on careless errors and right now that means I sit with him and I work on keeping him focused so he dosn’t skip steps. And organization. And chunking to avoid becoming overwhelmed. Maybe it’s not as bad as I fear it is.

I think it's a guy thing to be like hey let him tough it out, he'll be fine, blah blah. It's also totally incorrect to think (or anyone to imply) that choosing meds mean you're NOT to work on the EF issues. All this stuff you're describing is EF, and yes, yes, yes you want to work on it!!! Definitely definitely bring in everything you can find for EF. Tech, chunking strategies, SKLAR, 360 Thinking, etc. yes yes.

I'll tell you our story on the meds. We held out for a long time, made it work, she progressed well, and yes I was doing everything right there with her, blah blah. We got mid-way through high school and we were just DONE. We got the meds (at that point without the oh yes this is fine of the dh, who had been a stiff holdout), and her ACT scores went up, well they went up astonishingly. She went from scores that barely would have even gotten her into colleges to winning top scholarships at every college. Seriously.

In other words, the gap is not will he perform, can he survive. On some kids, the gap will be IS WHO HE IS COMING OUT? When it's that much of a disability, sometimes it's holding them back that much. And high performance is not an excuse not to give them the chance to let it ALL show. My dd's composite scores went up basically 50%, which was worth $$$$$$$$$ in scholarships. At some schools her scores would be a full ride. Where she is, it's 1/2 ride, which is fine because that's their top gig. Huge huge money, totally worth the amount we spend on meds, the amount we spend on services to get her the meds and keep her the meds. 

The biggest thing it did for her though was empowering her and making her confident. She goes in and she kicks butt with accommodations, with anyone who stands in her way. She's not at all bashful about what she needs and using it. Her scores and her ability to get out went up SO much that she knows who she is and what she has to give and what she can be with the meds.

Also driving stats are a LOT better for medicated ADHD. It's something to think about seriously. Driving was the tipping point for us, because dd decided she didn't want to drive without the meds. Way safer. And she doesn't look back at her childhood and wish for meds all the way, but she *does* wish we had done meds by 9th. That was her comment, that she wished she had had them two years earlier. And you're right at that point too, so I throw that out. For him to get confident in this change and be independent the way they're going to want him to be, the meds could really help. And yes, yes, do all your EF skill development. Get CBT, do a 360 Thinking workshop, on and on, all of it, love it. And if he wants meds, get the meds. 

Just so you know, with our ped meds are not a fast thing. I don't know about all peds. Like you hear about them being dispensed like candy, and at least here they're NOT. You get the psych eval, then the ped runs his own testing, then he meets with you again, then you try something, blah blah. So you've got maybe 6 months to do psych evals and the ped portion takes 3-4 months easily. And then you have tweaking the meds, finding what med you like and what dose. Some people are glorious on the first dose, first med, but some need some tweaking. We tried one, liked it, went up a fuzz, thought it was too much, went back down. But that's 3 months to get really stable with the meds, even with basically no problems at all. 

Now what you don't want to hear. The ps 504/IEP system is driven by failure. They're going to want to see failure and needs and problems (ie. the disability is affecting his ability to access his education) before they step in. That would be insane to let that happen during his 9th grade year. So if you're really not going to partially enroll or whatever, then you MUST transition him to how he'll have to work. No more Mrs. Nice Mom. 

[PeterPan]

Story is correct that if it is ADHD straight, with nothing else, a neuropsych is overkill. Around here they bill at 2-3X the cost of a clinical psych or school psych. You'll get screenings, but if there's nothing nothing else going on, it's overkill. With my dd, there was more going on, weird stuff the np caught but couldn't fully put words to anyway. You might find it more helpful to find a psych who actually specializes in ADHD and who does CBT and have them do the eval and then have them keep going with some CBT. That would actually be a really good progression.

I'm concerned about your comments on the social thinking, etc. Unfortunately, sometimes these psychs are so pigeonholed that they kind of gloss what more is going on. It's common to have *some* social delay with ADHD, but at the highest end ADHD merges into ASD. You want to think honestly about whether that is possibly happening and get someone who is skilled at digging in on that. 

This might interest you The Social Thinking-Social Communication Profile

[Storygirl]

55 minutes ago, PeterPan said:

Now what you don't want to hear. The ps 504/IEP system is driven by failure. They're going to want to see failure and needs and problems (ie. the disability is affecting his ability to access his education) before they step in. That would be insane to let that happen during his 9th grade year. So if you're really not going to partially enroll or whatever, then you MUST transition him to how he'll have to work. No more Mrs. Nice Mom. 

Yes. The school will not care to evaluate if they think he is doing fine. And by fine, I mean average. The schools are not in the business of looking at average kids and saying "will this kid excel if we evaluate him?" Most kids are average, by definition. So if a student who could be getting A's is getting C's... the school may just consider him a C student.

However, if you have an outside diagnosis that shows attention issues are affecting schoolwork, you as the parent have more reason to ask the school for accommodations. (They do not necessarily have to run full evaluations for the school to set up a 504, by the way, just for an IEP.)

So if you decide to wait and see how he does in school and ask the school to run evaluations....the school MAY not see the need. I say "may" because I, of course, don't know your son or how significant the issues are. There are severe cases of ADHD that are obvious to the school personnel, as well.

ETA: I am just making up grades as examples. I don't know what kind of student your son is, of course.

Also, just as an example, DD16 has no LDs and no ADHD, and she tends to make a lot of careless errors in her schoolwork. Her teachers wouldn't think she has EF trouble, due to her careless errors. So a school is not going to necessarily pick up on the same focus and attention things that you do. If nothing else, for the simple reason that the teachers have 25 kids to pay attention to, and you can zero in just on your son, so you are going to notice things they will not.

Edited September 13, 2018 by Storygirl

[Storygirl]

And my kids are enrolled in school and are getting great help (I have two with IEPs and one with a 504 and one typical student). So I am not saying that schools don't want to help.

Just that they may not identify the same issues that you have seen, because they will work with your son differently, and their expectations are different. Therefore, I would not wait and depend upon them to figure the ADHD thing out for you.

Edited September 13, 2018 by Storygirl

[mamaraby]

I really do not think ASD is an issue here. Truly.

I did call the health insurance today to verify whether or not the exclusion I found related to ADHD. They confirmed that the ADHD screening and treatment would fall under our mental health coverage - providing it’s medically necessary. I’m working my way through local providers. I’ve got one who requires dx by psychiatrist and then they can provide treatment. I have a call into a second place that has a psychiatrist on staff. I did get a good rec on that particular provider, but I have no idea if they can see us sooner. I’m still keeping our other appointment for next year and we’re on the cancellation list. Next year I have to meet the deductible in full before the health insurance pays anything so this year would be nice. I probably should have started this process earlier. It’s just that it didn’t reall coalesce in my mind until recently. 

I’ll keep pushing forward. It does sound like getting an answer is the way to go.

[PeterPan]

Psychiatrist or psychologist?? When a psychologist does an eval and diagnoses ADHD, they're usually running a full eval. At a minimum it will be achievement testing, IQ, an EF survey, something often for behavioral (depression, anything they see flags for), and they're gonna read the tea leaves on stuff like SLDs and screen for anything that needs referrals like OT or SLP or vision. A psychiatrist is an MD who has additional specialization, and I just don't know what they do with ADHD. An MD can diagnose ADHD, sure. Around here, they'll usually do that same EF tool the psychologist runs, no IQ or achievement or anything academic, and they'll often have some kind of tap tap attention test like the Quotient. The psychologist will usually have some kind of tap tap continuous attention test too, though in my experience the one the MDs use is different. So the psychs might have the TOVA and the peds around here use the Quotient. You can google them and see.

So anyways, if you do an intake with a p-doc because you want meds, fine. Around here a p-doc is $300 an hour and my ped is like $80. A clinical psychologist around here is maybe $140 and a neuropsych, last time I priced 5 years ago, was over $250 an hour. So you can see that a pdoc is the MOST expensive way to get meds AND the most expensive way to get a diagnosis. If you're paying part of this, that matters! And, when you're saying you want documentation to take to a school, want to know how it impacts learning, want it to change your homeschooling, again we're back to needing the IQ, achievement testing, and all that screening. That stuff kicks out data on processing speed, working memory, and all kinds of subtle stuff. I just don't get why they're telling you to go to a p-doc for the actual eval, since that's usually a psychologist.

You know, try to get someone to do the SLDT, the TOPS, and maybe the TNL. The TNL would depend on how he is doing with language. How is he with writing and getting out his thoughts and getting them organized? The SLDT and TOPS can turn up some things in these kids, and they're actionable. Sometimes, sometimes a psych (psychologist) will have them, and sometimes you need an SLP. Just more depends on who bought them, not whether they can run them. But given that you've had some social questions over the years, running a few extra tools like that might be wise, just to catch things. You can look them up and see. You can usually tell from the samples oh yeah that would show things or oh no he'd fly through that. Some other tests psychs use will have a pragmatics component, but I like these tests. Something like the pragmatics portion of the CELF (which a neuropsych is likely to have) is just worthless for this.

Just to spread your net, you could try the Hoagies Gifted list for psychs. Those psychs are gonna see a lot of ADHD. And also if you're willing to drive a bit, sometimes you can find a gem.

That seems weird that a clinic wants you to have a diagnosis by a p-doc before they'd see you. Are you sure they didn't mean a psychologist?? And what kind of clinic was it? So many of these places doing EF work with ADHD are SLPs, and they wouldn't care about that, mercy.

Yeah, you can have long waits to get in. It's good that you're going to be able to start now! This choosing stage takes a while, but it sets you up for the rest to go well.

Edited September 13, 2018 by PeterPan

[mamaraby]

Well, it doesn’t matter what the place who turned us down wanted or why they wanted it because we’re not going there so it’s a non-issue as far as I’m concerned. Crossed off the list, moved on.

Our appointment is with the neuropsychologist the ped told us evaluates all the kids they send out for evals. There was no offer of meds on his part. My assumption there is that he won’t do anything until the neuropsychologist does the eval. We had two to choose from. The one does three appointments. The other does one big 4-hour appointment. We have an appointment with the second one because the first was booked out to February.

The third place I have a call out to has a psychiatrist on staff, but I’m not sure how they handle evals nor how much it will cost nor even if they can see us earlier than January. I’ll have to ask when they call me back.

At this point, it’s looking like my January appointment the ped referred us to is the best I can do. I was trying to save some money by not doing three separate appointments given how my insurance pays, but the recommendation I got locally says the better of the docs is the one who does the three appointments. She’s booked out until February. 

[PeterPan]

Yes, being booked out is a sign that the word on the street knows who the better psych is. So you're talking January vs. February? It's worth it to do this eval right. Check, but probably the psychs bill about the same and the one is spending more hours, hence the higher price. More hours is almost always more better when it comes to these evals. Also, many psychs don't like to do one long appt unless it's totally unavoidable, because they want to see the client over a number of days to see the breadth of his behaviors and responses.

Although it's an expense this time, then the ps can do your updated paperwork for college entrance testing possibly so that it doesn't cost you so much. That's what I did with dd. 

Edited September 13, 2018 by PeterPan