Case study: Digital test provides quick and clear data for ADHD diagnosis
Diagnostic challenges lead to delays in treatment
An estimated 3-5% of school-age children are affected by ADHD in the UK, with core symptoms of inattention, impulsivity and hyperactivity. Like many mental health disorders, ADHD can take a long time to diagnose and there can be a discrepancy in diagnosis depending on where a patient is seen. Information is gathered from parents, teachers and young people in order to reach a diagnosis, and they may give contradictory perspectives. With an average delay of 18 months from the first clinic visit to diagnosis, there is a huge burden on health and education systems, and resulting frustration for patients and families.
“Timely access to interventions is crucial to longer term outcomes - school time can be difficult for children and if there are delays to treatment and intervention there can be an impact on their school work.” says Dr Charlotte Hall, a Research Fellow in the Faculty of Medicine & Health Sciences at the University of Nottingham, who led the clinical trial.
A digital intervention with a clear visual result
The use of a computerised test of attention and activity, called the Qb test, was proposed as a way of adding objectivity into diagnostic assessment. Dr Hall and her colleague Professor Chris Hollis set up a clinical trial to measure the impact, speed and accuracy of diagnostic decision-making in children with suspected ADHD. The trial was funded by The NIHR Collaboration for Leadership in Applied Health Research and Care East Midlands (NIHR CLAHRC East Midlands) and was supported by NIHR MindTech MedTech Co-operative, a national centre focused on the development, adoption and evaluation of new technologies for mental healthcare and dementia.
Participants between 6-17 years old were assessed as usual as well as taking a 20 minute test in which they respond to target stimuli while ignoring other stimuli. The test measures attention, impulsivity and activity via a ball on the participant’s forehead and although the first few minutes are easy, it becomes harder as it goes on.
Qb compares a child’s performance to a normed child age performance, and crucially this is not based on academic year groups but the child’s age at the time of completing the test. Within minutes, a graph is produced to show families and clinicians visually where the child is and where their peers are. Half of participants got to see the test result and the other half were put into the blind arm in order to compare the impact of the test on diagnosis.
Dr Julie Clarke is a consultant community pediatrician and coordinated the trial at the United Lincolnshire Hospital Trust, where she works. She saw immediately how the test could help clinicians and families: “As soon as I started to see the results it was obvious to me as a clinician that this test could be an absolute saviour, as much for ruling out diagnosis as providing one. Having something as objective as this Qb test meant helps patients with ADHD to get a better and quicker diagnosis and those who don’t get clearer information.”
The trial found that patients whose clinicians saw the Qb test report were 44% more likely to receive a diagnostic decision within six months. The likelihood of correctly excluding ADHD within this time is also doubled. Where the test was used, clinicians saved time and felt more confident in their diagnosis and 85% of patients surveyed suggested that the test helped them to better understand their symptoms.
Updating the approach across the East Midlands and beyond
At the end of the trial, Dr Clarke found it hard to let go of the kit and persuaded the company to let her and her team keep it while they built the business case to fund longer term use of Qb in diagnosing ADHD.
Julie Clarke says: “We have evidence that it achieves two clinical goals: it improves quality of care and patient experience while saving money and time. We redesigned the ADHD pathway and have applied this to every child who is referred. At the end of the year we audited the results from across the East Midlands Academic Health Science Network (AHSN) and the evidence was overwhelmingly positive, convincing the Trust to buy the equipment.”
In practice the team has found that it is most efficient, both for patients and financially, to run the test on one site rather than across several. Patients travel from across Lincolnshire to the test centre where they also get support with the paperwork that remains part of the diagnostic assessment.
In a study of user experience, one of the parents of a child who was tested with Qb said: “It’s a big decision to allow your children to have these drugs, as it were. So, again, seeing those results made me more confident that yes the medication would help him.”
Another parent said: “I only see what he’s like at home so it was nice to see what he has done [in the QbTest] to help me understand it”
Charlotte Hall believes it would be beneficial to look at the longer term impacts; the trial looked at diagnosis up to a six month period and it is not possible to draw conclusions about the impact of Qb on the third of patients who did not have a diagnosis in this time.
For Julie Clarke there has been another striking effect: “I’ve lectured a couple of times for the British Association of Child Health and at the end lots of paediatricians come up to me and ask to come and see the test. It has not been difficult to convince others of the benefits!”
The East Midlands AHSN is beginning to roll this out to other networks in England as one of their most successful results ever and the team was recognised with a Health Services Journal award in 2018 for Innovation in Mental Health.
The research reported in this paper was funded by the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East Midlands (CLAHRC-EM). The research was supported by the NIHR MindTech Healthcare Technology Co-operative.