Child psychiatrist Professor Chris Hollisof Nottingham University is running a randomised controlled trial to find out whether using the test can speed up the process of reaching an accurate diagnosis in kids who have been referred for an ADHD assessment. “We were surprised to find that 40% of children referred for assessment still don’t have a diagnosis after six months. Families face long delays in assessment and then treatment if the diagnosis is confirmed. Tools such as QbTest can be helpful in ruling out ADHD so we can look for other issues,” he says. “It can also give objective evidence to support the diagnosis of ADHD which helps to reduce stigma and may make treatment better accepted.”Hollis says that recognition of ADHD has been held back by misunderstanding. Kids with ADHD may develop behavioural difficulties as a result of their condition, but he adds that “ADHD is not about bad behaviour”. The main problem is the way the brain manages information, and ADHD is as real as autism, dyslexia and other developmental brain disorders. About one in 50 children has moderate to severe ADHD. Rates of diagnosis and treatment have increased hugely from the 1970s when ADHD was considered rare.
Hollis says the increase is due to better recognition, though the growth in the use of medication has plateaued in the past eight years, with about seven in 1,000 children in the UK receiving it. Rates of medication use in the US are five to 10 times higher, and treatment there is sometimes started in children under five years old – which is very rare in the UK.
Kids with ADHD will still often fall behind at school for difficulties that are not their fault. “I think it’s appalling” says Hollis. “There’s still so much stigma and misinformation.” Hollis thinks behavioural therapy and information for parents can help them manage better, and that teachers and employers need to be better informed about the condition. Plenty of exercise, sleep and a healthy diet are good for all children, but a lack of any of these doesn’t itself cause ADHD. “Although coaching can help individuals, the evidence for non-drug therapies such as behaviour therapy and cognitive training reducing ADHD symptoms is disappointing,” he says.
The most effective treatment remains stimulant medication (methylphenidate, dexamfetamine) or the non-stimulant atomoxetine. They appear to work by enhancing the action of the naturally occurring neurotransmitters, dopamine and noradrenaline.
Hollis can’t understand why there is so much resistance to drug treatment when the drugs have been shown to be more effective and safer than many other commonly used drugs. “If your kid had diabetes, you wouldn’t hold back on starting insulin,” he says.
Kustow thinks online tests are useful, but limited. “They are a snapshot and can be a useful aid, but will never replace clinical assessment. You need to find out how the person has functioned since childhood, and screen to see whether they have other physical and mental health problems.” But he acknowledges the tests can be particularly helpful in ruling out ADHD or adding weight to a diagnosis in complex cases.
ADHD usually presents in childhood, but the impairing symptoms persist into adulthood in up to 70% of cases. Undiagnosed and untreated adults often have problems holding down a job or staying in a relationship. “This disorganisation and procrastination affects jobs and relationships, leads to anger management problems, mood swings and high stress levels. The stress may come out as depression and anxiety, alcohol and substance abuse and physical problems such as high blood pressure,” explains Kustow.
In Sweden, where criminal, health and social care records are linked,, researchers have found people convicted of crimes are much more likely to have ADHD than the rest of the population. Estimates suggest 7-40% of people in the criminal justice system may have it or other similar disorders, though many won’t have a formal diagnosis. A study in the New England Journal of Medicine found when criminals with ADHD took their medication, reoffending rates fell; they were 32-41% less likely to be convicted of a crime when they were taking the medication than when they were off it. “Taking ADHD seriously could have a significant impact on our whole society,” says Kustow.
Do I have ADHD?
The QbCheck includes a checklist to ensure quiet test conditions, a self-rating symptom check, an explanatory video then the 20 minute test itself. It’s like the card game “snap” with a built-in time lag. One of four symbols (red and blue circle and square) flash up on the screen one at a time, every 2 seconds. If the symbol on the screen is the same as the one immediately before, I click on the mouse. If it’s different, I don’t. Sounds easy? It really isn’t. I start off OK but it’s increasingly hard to stay focused on the boring and repetitive task. Random thoughts intrude; I want to change position, I’m hungry, I’m anxious I’ll fail. Bugger, was that a red or a blue circle? I’m aware of pulling myself back to the task, tell myself not to panic. In the end, I do surprisingly well – no mistakes, very consistent, not much fidgeting. I can’t help wondering if being completely absorbed in a boring task is a “good thing” but I can see it’s useful in the world we live in. My family’s sceptical as I’m notoriously restless and easily bored. But hopefully my patients will be pleased that I can focus if I need to.
