#QbTest #bringing #objective #approach #ADHD #diagnosis

Despite being a strong student in high school, Sydney Dodini struggled during her freshman year at Brigham Young University. She kept showing up late to lectures and found it difficult to focus during class. When she flew home in the spring, she asked her father, Aaron Dodini, a psychologist who specializes in ADHD testing, to give her a QbTest, an FDA-cleared ADHD diagnostic screening tool that can be done online.

ADHD, or attention deficit/hyperactivity disorder, is one of the more common neurobehavioral disorders usually first diagnosed in childhood and which can continue into adulthood. Symptoms fall into three categories: inattention, manifesting in difficulty sustaining focus, staying on task, and staying organized; hyperactivity, including excessive fidgeting, extreme restlessness, even talking too much; and impulsivity, including difficulty with self-control, delaying gratification, and considering long-term consequences. But Sydney Dodini didn’t display the classic symptoms. “I thought I was being dramatic,” she says, noting that she probably wouldn’t have asked for the test if her father hadn’t had easy access to it.

Aaron Dodini also didn’t think his daughter had ADHD, but still gave her a QbTest. During the roughly 15-minute computer-based test, the patient is recorded as they are shown one of four shapes every two seconds on a computer. The moment the same shape appears twice in a row, they have to hit the spacebar. The program combines an assessment of attention ability with a movement analysis based on an infrared measurement system. Results are compiled into an overall score, which is compared with data from a control group consisting of people of the same age and sex who don’t have ADHD. Patients also can see how their head movements compared to that of the control group, and how they scored on the three axes of ADHD: inattentiveness, hyperactivity, and impulsivity.

According to her results, Dodini was diagnosed with ADHD. Now 21, she’s treating her disorder with stimulant medication. “It doesn’t erase ADHD but it makes my life more livable; it gives me the tools to succeed and excel,” she says. Entering her senior year of college in the fall, Dodini is passionate about making ADHD testing more accessible to others because the diagnosis and treatment have changed her life.

[Photo: Qbtech]

Her father, meanwhile, has a new perspective on ADHD. “I’d been living with her my entire life, and I didn’t see it,” he says. “I needed the objective data.”

Over the past few years, interest in ADHD has been trending. Literally. On TikTok, videos with #ADHD have racked up 12.6 billion views. (TikTok has about 1 billion monthly active users.) Since the beginning of the pandemic, Google searches for ADHD have nearly doubled, with many users attempting to self diagnose.

A difficult diagnosis

Diagnosing ADHD by physicians has been dogged by controversy ever since the condition was added to the Diagnostic and Statistical Manual for Mental Disorders (DSM) in 1980. No one has hit upon a foolproof way to identify it, which means ADHD is paradoxically both under- and overdiagnosed. Traditionally diagnosed through psychologists who take a patient’s clinical and personal history over the course of several hours to make an assessment, or via a neuropsychological evaluation that tests for other learning disorders and includes I.Q. testing and visual spatial skills.

The first approach can cost several hundred dollars; the second promises more accuracy but can cost up to $9,000. Both methods are effective, to varying degrees, but getting evaluated and tested for ADHD can be expensive and time-consuming, and girls and children of color are much less likely to go through the process and receive a diagnosis than boys.

Today, globally, boys are three times more likely to be diagnosed with ADHD than girls are. (In the 1990s, they were nine times more likely.) And Black children are 70% less likely to receive an ADHD diagnosis than white ones. (The New York Times recently published a story on how women and people of color are starting to explore ADHD diagnoses because of the social media explosion.)

At the same time, diagnoses of ADHD have increased steadily since the 1990s. According to a 2016 study of children and adolescents in the U.S., ADHD diagnosis rates increased from 6% in 1997 to 10% in 2016. And a 2021 review of 334 studies found that ADHD tends to be overdiagnosed in children and adolescents, particularly for those with mild ADHD.

All of these studies point to an imperfect ADHD diagnostic process, one that’s riddled with bias. “Clinicians and physicians may believe they can make accurate diagnoses with subjective questionnaires or observational data,” Dodini, the psychologist, says. “But without objective data, we are still blind to the actual symptoms and their severity relative to age and sex.”

QbTest is poised to bring some needed clarity to the diagnostic process by taking the subjectivity out of ADHD testing and allowing people to be diagnosed affordably and online with a telehealth-friendly version of the test, called QbCheck. Both versions of the test function as a supplement to the traditional clinical interview. “Our tests are not stand-alone. They are there to support the diagnosis process,” says Tony Doyle, commercial director of Qbtech, the Swedish company that created and produces the tests; and which has been focused on a technology-first approach to ADHD assessment since 2000.

The need for objective assessments

Telehealth seemed like a promising way to expand access, yet the quality of diagnosis offered by telehealth companies can vary. According to a survey of 872 patients by the ADHD magazine ADDitude, 66% of  telehealth users said the diagnosis process lasted less than an hour, and only 52% said their provider asked for a family medical history. Two telehealth companies, Cerebral and Done Health, have both recently come under fire for overprescribing ADHD medications. Both companies offer a short, self-reported quiz before allowing patients to speak with a physician who can prescribe medication.

But Cerebral is facing a Department of Justice investigation for overprescribing controlled medications, including Adderall; this past April, CVS Pharmacy stopped filling prescriptions from Cerebral and Done Health. A representative from Done noted that the company is committed to patient safety and well-being, and the diagnostic process includes filling out three self-reported questionnaires, as well as a half-hour telemedicine consult. Cerebral did not respond to a request for comment.

West Chester, Pennsylvania, psychiatrist Ari Tuckman has been diagnosing ADHD since the late ’90s and has written four books on adult ADHD. He notes that while ADHD medications are generally stimulants that are safe, companies like Cerebral and Done may have taken shortcuts during the diagnosis process. “Being too quick on the trigger with a diagnosis and/or treatment means that some people will be treated in less than optimal ways, resulting in likely worse side effects and less benefit,” he says.

Also, as with most people taking medication for a condition, patients may still need care or to be monitored after starting treatment. Dodini warned that telehealth prescriptions should be paired with a clinician relationship to monitor how well an ADHD diagnosis and treatment are helping to alleviate or better control symptoms. “If clinicians don’t use the most accurate tools available to get valid diagnosis and there is no relational oversight, the patient is not getting the highest standard of care available,” he says.

Bringing an objective assessment to the historically subjective process of diagnosing ADHD has a twofold potential benefit: helping make the process less uneven, and bringing down a key barrier to entry—cost—for patients looking for a more accurate diagnosis.

QbTest positions itself as bringing objectivity, accessibility, and a high standard of patient care  to the world of ADHD diagnosis by supplementing a clinician’s diagnosis. The test, which was cleared for use in Europe in 2003 and in the U.S. in 2004, places a patients’ results in context, helping eliminate the gender bias around diagnosis. (Qbtech has not broken out its data by race.) According to a 2015 study by a Swedish governmental clinic, QbTest’s ability to correctly identify ADHD in people is more than 70%. However, the study warned that QbTest did an “unsatisfactory” job of accurately identifying the different types of ADHD: hyperactivity, inattention, and impulsivity. It also offers physicians the ability to retest patients when they are on medication to gauge if any dosage changes need to be made.

Today, Qbtech’s tests are used by roughly 10,000 clinicians worldwide—ranging from primary-care physicians to specialists in psychiatry and neurology. Nearly half are based in the United States, and since the company rolled out the telehealth-friendly version in April 2020, 68% of the clinicians it works with have adopted it. Most offer it alongside an in-office test, and 11% offer QbCheck exclusively online.

[Photo: Qbtech]

Some clinicians, like New York City psychotherapist David Sitt, who specializes in the assessment and mindfulness-based treatment of ADHD, see diagnostic tools like the QbTest as balancing accessibility and diagnostic rigor. “QbTest could offer a valuable middle ground,” he says, between a quick-and-dirty online diagnosis and an expansive—and expensive—neuropsychological profile. The QbTest assessment costs $70, though the company advises that it be administered and reviewed by a qualified clinician, who will charge an additional fee. (Dodini, for example, charges $525 for the test and consultation.)

As an expert in creating those neurological deep dives, Robert H. Reiner is a strong proponent of using objective means to diagnose ADHD. At his New York City clinic Behavioral Associates, he offers qEEG testing (quantitative electroencephalogram), which costs between $500 and $1,500. A qEEG test creates maps of patients’ brains. A higher ratio of theta waves to beta waves can be an indicator of ADHD. Reiner compares the patients’ beta-to-theta-wave ratio to a database he has of people without ADHD. Yet, qEEG is also controversial, and studies vary on its accuracy. “No single instrument is 100% accurate for diagnosing a condition,” Reiner says.

Both the qEEG and QbTest are hard to game, according to Dr. Gary Kanter, an associate professor of psychiatry at the University of Florida College of Medicine. Having diagnosed and treated ADHD since 1984, Kanter says the QbTest can help prevent overprescription to patients who might study up on symptoms to get medication. Tuckman went so far as to say that if you try to pretend you suffer from ADHD when taking the QbTest, the pattern of your results could suggest you have brain damage.

A life-changing diagnosis

One point all the providers I spoke with agreed on: An accurate ADHD diagnosis can help change the direction and quality of a person’s life, particularly poignant for children and adolescents.

When 12-year-old Christopher Cayton was in preschool and elementary school, he was often expelled for violent behavior. Diagnosed at one point with oppositional defiant disorder, he was prescribed medication and therapy, but nothing that really helped. He was hospitalized three times for self-harm and eventually went to a residential program where he spent all of second grade, but still he wasn’t getting better. Finally, in fourth grade, he was given a QbTest and ultimately diagnosed with ADHD. His doctor was able to make adjustments to his medication by retesting him every few months to start. Recently, Christopher finished 6th grade with straight As. His mother, Lisa Hitson, tries not to dwell too much on her son’s elementary school years, but she’s angry about how difficult it was to get the right diagnosis. “It caused years of unnecessary suffering and emotional trauma,” she says.

When I was diagnosed with ADHD in high school, it came as a surprise. I didn’t fidget, got good grades, kept my room tidy, and had a decent memory. I did have trouble paying attention in science and math classes, but I made it through AP Physics and BC Calculus. In college, my advisor asked if my diagnosis could have gotten mixed up with someone else’s. Though I never felt the need to pursue medication, the diagnosis left me with questions. So I was curious to see if the QbTest would offer me some clarity around my own diagnosis.

The test would be a piece of cake, I figured, because I really didn’t believe I could have ADHD. A couple of minutes into the exam, I suddenly understood what providers meant about it
being hard to game. I was so bored that to cope, I pretended I was a dragon and that each shape was a villager I needed to destroy. Then I decided being a violent dragon was against my nature and started wondering how to forge cooperation between dragons and people, which opened up a whole different can of worms. I even wondered, at one point, if I could bribe my husband to take the test for me.

But I did complete the assessment; and when my test results came back, they showed that I did, in fact, have ADHD. I haven’t discussed the outcome with a clinician and, to date, have no plans for medication. However, this time, I believe the diagnosis because I can see how my results stack up against those of other women in my age group. (I’d still love to see how Asian women my age did.) For the first time in my life, I was able to forgive myself for struggling with science and math classes. This is a relatively minor outcome. But for people like Sydney and Christopher—and all those fighting daily battles of hyperactivity and/or attention deficit without understanding why—an ADHD diagnosis can be the difference between surviving and thriving.



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