Multifactorial: technology and the modern ADHD assessment
Dr Venkat Reddy MBBS, MRCP, FRCPCH, Consultant Neurodevelopmental Paediatrician and Lead Clinician is a technology disruptor; a passionate advocate for the use of technology across all aspects of modern healthcare.
Talking to him (via Zoom) you understand that what he is most passionate about is where the human, user experience of healthcare intersects with technology. When it comes to ADHD care specifically, he has been the driver of change; helping NHS trusts embrace evidence-based technology to support clinicians in the fact-finding process behind each and every ADHD assessment.
In this guest blog, Venkat talks openly about the multifaceted nature of neurodevelopmental assessments in the modern age and where we may head thanks to technology.
ADHD is a social construct
Children of today are expected to sit still for 6 hours of the day at school. It is the modern society that values attention and focus. When it comes to an ADHD assessment, we, as clinicians, have to respect the fact that the various stakeholders, the families/ primary caregivers, the school, and the teachers have their own motivations for wanting that child to be assessed and diagnosed. Everyone is trying to do their best – most of the time.
For example, the teacher that wants extra support for that child if they are acting out in class and causing a regular disruption will have her own perspective. Similarly, either parent/caregiver can be for or against an ADHD assessment or diagnosis based on their personal beliefs or motivations. These perceptions can influence which child is referred, how symptoms are reported, and what diagnosis is acceptable. Even when the symptoms are accurately reported and accepted by parents and teachers in different settings, the attribution can vary. The advantages and disadvantages of diagnosis and drug treatment are very personal and subjective.
In some cases, the various stakeholders can be binary and contradictory in their reporting of issues, problems, and symptoms. A child’s behavior can be described as very good or very bad with no in-between. This can make it challenging to quantify the actual impact of behavior on their academic and social development.
In Peterborough, where I practice, I work with a diverse, multinational, and multicultural community from all over the world. A common thread for patients and families I see from these communities, who do not have a cultural and social concept of ADHD, is that they are often motivated to avoid neurodevelopmental assessments because they are afraid of the stigma and want to avoid labels being put on their child.
Culture also has an influence on these discussions. Having grown up in India, it is not uncommon for children to grow up exhibiting hyperactive traits; running around and playing. You may be in a lesson with up to 100 other children in secondary school. You also grow up to respect authority figures; if a teacher asks for quiet, you stop talking and listen – this is ingrained from an early age. There is evidence to suggest that the severity of ADHD has strong links to culture.
For these reasons and others, it is so important for clinicians to understand each child’s history and ask lots of questions. It can take many years of practice to gain the skills to gather all the evidence. It can be tempting to avoid asking difficult questions to parents about the child’s symptoms and the family history of Adverse Childhood Experiences, as conditions such as attachment disorder and foetal alcohol syndrome could mimic ADHD. If a child is hungry, worried about parental mental health, or witnessing domestic violence at home, how can they possibly be expected to concentrate in the classroom? Without a comprehensive biopsychosocial assessment, it can be easy to jump to conclusions.
Adding QbTest to our care pathway for ADHD helps us gather information on a child’s core ADHD symptoms, excluding all other factors. Patients sit to complete a 15-20 non-stimulating task in a quiet room under professional supervision. This test allows us to collect data on their attention, activity, and impulsivity. The report shows us a comparison of their performance against a norm group of patients of the same age and gender, something that I find particularly useful. Some parents will say that the test doesn’t replicate their struggles in the real world, which is a valid point to make, but objective information about the child in a controlled environment is beneficial for diagnostic formulation.
However, as the clinician, it is useful to control for these external factors as it can help me to structure my questioning, playing a detective-type role to get to the root cause of the reported behaviour. I interview the various stakeholders to understand the child’s intellectual abilities and the environment they are functioning in.
It is adding objective data to match against the subjective feedback that can help me to differentiate between various causes of inattention and hyperactivity. Often, QbTest is useful to help rule out ADHD as the reason for inattention and hyperactivity, so that appropriate alternative assessments and interventions can be provided for conditions like Learning Disability and Attachment Disorder.
QbTest is now part of our toolset, offering a visual representation of a patient’s symptoms – which patients, their families, and the teachers can easily interpret and understand. Ultimately ADHD is a clinical diagnosis made by an expert clinician after evaluating evidence from the child, the family, the school, clinic observation, and the data from the QbTest.
Back to the future of ADHD care…
Increasingly, I see technology playing an important role in allowing healthcare organizations to be more thorough, efficient and accurate in their diagnoses and treatment. Part of my role and my work with commercial partners is to support this increased confidence in technology for us to do what is best for patients. In the context of ADHD and other neurodevelopmental disorders, I envisage the evolution of technology to support patients in the moment at the point of performance when they most need intervention. Children with ADHD respond best to immediate positive feedback and consequences as close to any particular action as possible since short term working memory problems make it difficult for children with ADHD to learn from their mistakes if the consequences are delayed for a long time after a particular action.
With that in mind, the future lends itself to allow patients and families to get personalized care using technologies such as wearable smartwatches to gather biomarkers like movement and heart rate to diagnose and monitor ADHD. Machine learning algorithms can help to make sense of the big data generated by the continuous measurement of biomarkers. The best way to understand is to think about this as a form of continuous QbTest feeding us the data about attention, activity levels, and impulsivity related to time, environment, and medication. Measurement of heart rate, blood pressure, and mood can be useful to monitor the use of medication.
Here’s a hypothetical example. With the patient and family’s permission, you could use existing technology to create alerts for both patients, teachers, and caregivers when a patient is likely to act out based on blood pressure, heart rate and other data collected. This would allow children to gain some awareness of what situations trigger inattentiveness, impulsivity, or angry outbursts – common features of ADHD. At the same time, this data would also allow teachers, parents/ carers an opportunity to intervene before the behavior escalates. This is one use case, the possibilities are limitless, and could be implemented for a range of situations in life that ADHD may influence; eating habits, sleep habits, memory, use of technology, and so on.
Children and families with ADHD, often feel like they are on the back foot and in a reactive mode; dealing with the fallout of behavior and the symptoms of ADHD that have already happened. With technology, we can use data to put children, parents, and caregivers on the front foot, anticipating behavior changes and preventing problems.
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