Behavioral Assessment of Core ADHD Symptoms Using the QbTest

Absent or Hidden? Hyperactivity in Females With ADHD

OBJECTIVE

This study aimed to objectively assess signs of hyperactivity in adults suspected of having ADHD, addressing potential sex bias in diagnosis.

METHODS

About 13,179 (49% female) adults with an average age of 33 years with ADHD and 1,910 (41% female) adults with an average age of 36 years without ADHD were included. Motor activity was measured using the Quantified Behavioral Test, analyzing "provoked," and "basal" activity. Sex by group differences were analyzed using analysis of variance.

RESULTS

Results showed significant ADHD effects on the basal and provoked activity measures, while sex effects were only notable for provoked activity. Males, irrespective of diagnosis, exhibited higher provoked activity than females, while both sexes with ADHD displayed approximately twice the basal activity and about three times the provoked activity compared to their respective sex controls.

CONCLUSION

These findings suggest that females with ADHD suffer equally from hyperactivity compared to males, challenging the notion of a sex-dependent presentation of hyperactivity. This may lead to more accurate and timely diagnoses, reducing ADHD-related burdens and comorbidities in females.

Towards an Objective Measurement Tool for ADHD-like Traits in Family Dogs: A Comprehensive Test Battery

Family dogs exhibit neuropsychological deficits similar to attention-deficit/hyperactivity disorder (ADHD) symptoms in humans. Questionnaire methods have mostly been used to assess ADHD-like behaviours in dogs. In addition to our validated questionnaire (Dog ADHD and Functionality Rating Scale-DAFRS; 2024), we developed a simple behavioural test battery covering the ADHD symptom domains (i.e., inattention, hyperactivity, and impulsivity) in dogs. Our main aim was (i) to provide a final external validation step to the DAFRS by examining its associations with the test variables (N = 59); and (ii) to compare owner- and trainer-rated factor scores' associations with the test variables (n = 38). We developed four tests covering the ADHD symptom domains: the attention test (inattention), the plush dog test (impulsivity), the leash test, and the sit test (hyperactivity). All four behavioural variables correlated with their respective questionnaire scores, i.e., the strongest for hyperactivity, and the least strong for inattention. Both owner- and trainer-rated scores (n = 38) correlated with the relevant test variables in an expected direction. Dogs' training status was linked only to the sit test results. Test-retest analyses (n = 34) indicated moderate-to-excellent agreement across all behavioural variables. Our findings support the validity of our novel human-analogue questionnaire for dogs as the behavioural tests strongly correlate with the relevant questionnaire scores, indicating that the two constructs together can effectively assess inattention, hyperactivity, and impulsivity in dogs.

QbTest for Monitoring Medication Treatment Response in ADHD: A Systematic Review

Introduction

Attention deficit hyperactivity disorder (ADHD) is considered one of the most common neurodevelopmental disorders in childhood and adolescence. Pharmacological treatment plays an important part in the therapy of the disorder and verifying the effectiveness of ADHD medication is essential throughout the course of treatment. QbTest is a computerized test, for which intended use is to provide healthcare professionals with objective measurements of hyperactivity, impulsivity, and inattention to aid in the clinical assessment of ADHD and the evaluation of treatment interventions.

Methods

A systematic review of relevant articles was conducted for which QbTest was used for monitoring medication treatment response in ADHD. Literature published between 2004 and 2023 was appraised.

Results

A total of 15 studies were included in the review. Thirteen articles involved subjects diagnosed with ADHD and two studies that were related to the disorder, which evaluated QbTest in medication treatment response. Changes in QbTest data such as Q-scores, effect size, or improvement/deterioration of QbTest variables were evaluated. A clinically relevant decrease in QbTest Q-scores was found in the majority of the studies when treated with any type of ADHD medication in therapeutic doses, both in comparison to placebo and when compared from baseline to endpoint treatment.

Conclusion

QbTest can distinguish pharmacological treatment effects within hours of pharmacological titration and can be used for monitoring of long-term treatment of ADHD. A need for optimization and individualization of medication treatment response could be addressed with access to objective measures in ADHD management.

The Structure and Diagnostic Accuracy of the QbTest in Pediatric ADHD: A Retrospective Clinical Study

OBJECTIVE

The QbTest that combines a continuous performance task (CPT) with a motion-tracking system may help identify attention deficit hyperactivity disorder (ADHD). This study examined the structure and diagnostic ability of the QbTest in children and adolescents.

METHOD

Retrospective data from 1,274 children and adolescents were analyzed. The study assessed data on a principal component analysis (PCA), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

The QbActivity component included the variables micro-events, distance, area, and time active; the QbImpulsivity included normalized commissions and commissions (anticipatory errors were added in a version for 6-12-year-olds only); and the QbInattention included omissions, reaction time, and reaction time variation. Sensitivity ranged between 22% and 50%, specificity 79% and 96%, PPVs 40% and 95%, and NPVs 24% and 66%.

CONCLUSION

The structure of the QbTest with three cardinal parameters and nine/ten CPT and motion analysis variables was supported. The diagnostic accuracy was found to be poor to moderate. Given that this is a retrospective study, the interpretation of diagnostic accuracy should be considered within this context.

A preliminary study of white matter correlates of a laboratory measure of attention and motor stability in attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a complex behavioral disorder, often difficult and time consuming to diagnose. Laboratory assessment of ADHD-related constructs of attention and motor activity may be helpful in elucidating neurobiology; however, neuroimaging studies evaluating laboratory measures of ADHD are lacking. In this preliminary study, we assessed the association between fractional anisotropy (FA), a measure of white matter microstructure, and laboratory measures of attention and motor behavior using the QbTest, a widely used measure thought to improve clinician diagnostic confidence. This is the first look at neural correlates of this widely used measure. The sample included adolescents and young adults (ages 12-20, 35% female) with ADHD (n = 31) and without (n = 52). As expected, ADHD status was associated with motor activity, and cognitive inattention and impulsivity in the laboratory. With regard to MRI findings, laboratory observed motor activity and inattention were associated with greater FA in white matter regions of the primary motor cortex. All three laboratory observations were associated with lower FA in regions subserving fronto-striatal-thalamic and frontoparietal (i.e. superior longitudinal fasciculus) circuitry. Further, FA in white matter regions of the prefrontal cortex appeared to mediate the relationship between ADHD status and motor activity on the QbTest. These findings, while preliminary, suggest that performance on certain laboratory tasks is informative with regard to neurobiological correlates of subdomains of the complex ADHD phenotype. In particular, we provide novel evidence for a relationship between an objective measure of motor hyperactivity and white matter microstructure in motor and attentional networks.

Identifying activity level related movement features of children with ASD based on ADOS videos

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that affects about 2% of children. Due to the shortage of clinicians, there is an urgent demand for a convenient and effective tool based on regular videos to assess the symptom. Computer-aided technologies have become widely used in clinical diagnosis, simplifying the diagnosis process while saving time and standardizing the procedure. In this study, we proposed a computer vision-based motion trajectory detection approach assisted with machine learning techniques, facilitating an objective and effective way to extract participants' movement features (MFs) to identify and evaluate children's activity levels that correspond to clinicians' professional ratings. The designed technique includes two key parts: (1) Extracting MFs of participants' different body key points in various activities segmented from autism diagnostic observation schedule (ADOS) videos, and (2) Identifying the most relevant MFs through established correlations with existing data sets of participants' activity level scores evaluated by clinicians. The research investigated two types of MFs, i.e., pixel distance (PD) and instantaneous pixel velocity (IPV), three participants' body key points, i.e., neck, right wrist, and middle hip, and five activities, including Table-play, Birthday-party, Joint-attention, Balloon-play, and Bubble-play segmented from ADOS videos. Among different combinations, the high correlations with the activity level scores evaluated by the clinicians (greater than 0.6 with p < 0.001) were found in Table-play activity for both the PD-based MFs of all three studied key points and the IPV-based MFs of the right wrist key point. These MFs were identified as the most relevant ones that could be utilized as an auxiliary means for automating the evaluation of activity levels in the ASD assessment.

Efficacy of Continuous Performance Testing in Adult ADHD in a Clinical Sample Using QbTest

OBJECTIVE

Continuous performance tests are widely used to aid diagnostic decision making and measure symptom reduction in adult ADHD clinical populations. The diagnostic accuracy of the Quantified Behavior Test plus (QbTest+), developed to identify ADHD populations as an objective measure of ADHD symptoms, was explored.

METHODS

The utility of the QbTest+ was investigated in a clinical cohort of 69 adult patients referred to a specialist ADHD clinic in the UK.

RESULTS

Scores from the QbTest+ failed to differentiate between patients diagnosed with ADHD and those who did not receive a diagnosis after full clinical assessment.

CONCLUSIONS

Based on our findings, we recommend clinicians are cautious when interpreting results of the QbTest+ in clinical populations. This study highlights the need for investigation into the lack of validation of commonly used objective measures in ADHD populations.

A Robust Movement Quantification Algorithm of Hyperactivity Detection for ADHD Children Based on 3D Depth Images

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood mental disorders. Hyperactivity is a typical symptom of ADHD in children. Clinicians diagnose this symptom by evaluating the children's activities based on subjective rating scales and clinical experience. In this work, an objective system is proposed to quantify the movements of children with ADHD automatically. This system presents a new movement detection and quantification method based on depth images. A novel salient object extraction method is proposed to segment body regions. In movement detection, we explore a new local search algorithm to detect any potential motions of children based on three newly designed evaluation metrics. In the movement quantification, two parameters are investigated to quantify the participation degree and the displacements of each body part in the movements. This system is tested by a depth dataset of children with ADHD. The movement detection results of this dataset mainly range from 91.0% to 95.0%. The movement quantification results of children are consistent with the clinical observations. The public MSR Action 3D dataset is tested to validate the performance of this system.

Investigating the Clinical Utility of the Combined Use of Objective and Subjective Measures of ADHD During Treatment Optimization

BACKGROUND

This study investigated the clinical utility of the combined use of objective and subjective measures of attention-deficit/hyperactivity disorder (ADHD) prepharmacological and postpharmacological treatment.

METHODS

Adults with ADHD (N = 77) completed the Quantified Behavioral Test, self-ratings of ADHD-related symptoms, and quality of life measures pretreatment and posttreatment.

RESULTS

The use of objective and subjective measures of ADHD-related symptoms during initiation and follow-up of pharmacological treatment resulted in significant improvements in quality of life after 6 months. Both objective and subjective measures captured changes in ADHD-related symptoms, with more patients showing clinically relevant treatment effects on objective measures. Convergence rates between objective and subjective measures were low to moderate, and improvements on these measures correlated with increased quality of life.

CONCLUSIONS

Objective and subjective measures of ADHD capture important components of the condition. The findings from this study have important implications for clinical practice.

A review of objective assessments for hyperactivity in attention deficit hyperactivity disorder

Hyperactivity is one of the three core symptoms of attention deficit hyperactivity disorder (ADHD) that is a common childhood mental disorder. Objective assessments of hyperactivity are seldom utilized compared with measures of inattention and impulsivity during clinical diagnosis and evaluation. Acceleration-sensitive devices (e.g., Actigraph) and motion tracking systems (e.g., QbTest) are two main groups of devices that can be used to objectively measure hyperactivity. The Actigraph and QbTest have good discriminant validity, convergent validity, and sensitivity to the effects of stimulants. Furthermore, the assessment setting (i.e., research laboratory, school, or home) can greatly influence the presence and severity of hyperactivity. Nevertheless, objective assessments for hyperactivity have poor ability to distinguish ADHD from other disorders, or among the three types of ADHD. Thus, further studies are needed to assess objective measurements of hyperactivity in terms of discriminant and convergent validity, test-retest reliability in different settings, and correlations with brain activity.

Self-management training vs. neurofeedback interventions for attention deficit hyperactivity disorder: Results of a randomized controlled treatment study

OBJECTIVES

Neurofeedback (NF) and self-management training (SMT) may be viable treatment options for patients with attention deficit hyperactivity disorder (ADHD) if they alleviate core symptoms, enhance the patients' self-concept and improve their quality of life (QoL). Aim of the current study is evaluating both interventions accordingly and to test whether specific improvements in core symptoms lead to more general improvements in self-concept and QoL.

METHODS

In a psychotherapeutic outpatient clinic in Germany, a total of N = 139 children with ADHD were screened for eligibility, of which 111 fulfilled inclusion criteria and participated in the study in accordance with the CONSORT 2010 statement. These were randomly assigned to NF vs. SMT interventions. Changes from pre- to post-intervention in core ADHD symptoms relying on parent and teacher reports (CONNERS 3) and objective tests (Qb-Test) as well as self-concept (interview with the children) and QoL assessments (using the KINDL-R self-report) were compared between patients receiving NF or SMT.

RESULTS

Significant improvements in ADHD symptoms were achieved similarly in both treatment groups, whilst QoL and self-concept improved after SMT only.

CONCLUSION

This treatment study provides further evidence that SMT and NF may reduce core symptoms, but SMT may also improve patients' self-concept and QoL and may thus in its current form be the favorable treatment option in naturalistic settings. However, several limitations of the current study implicate that further research is required before definitive conclusions and recommendations for clinical practice can be given.

CLINICAL TRIAL REGISTRATION

[www.clinicaltrials.gov], identifier [NCT01879644].

Clinical Conundrums When Integrating the QbTest into a Standard ADHD Assessment of Children and Young People

The uptake of the QbTest in clinical practice is increasing and has recently been supported by research evidence proposing its effectiveness in relation to clinical decision-making. However, the exact underlying process leading to this clinical benefit is currently not well established and requires further clarification. For the clinician, certain challenges arise when adding the QbTest as a novel method to standard clinical practice, such as having the skills required to interpret neuropsychological test information and assess for diagnostically relevant neurocognitive domains that are related to attention-deficit hyperactivity disorder (ADHD), or how neurocognitive domains express themselves within the behavioral classifications of ADHD and how the quantitative measurement of activity in a laboratory setting compares with real-life (ecological validity) situations as well as the impact of comorbidity on test results. This article aims to address these clinical conundrums in aid of developing a consistent approach and future guidelines in clinical practice.

The Quantified Behavioral Test Failed to Differentiate ADHD in Adolescents With Neurodevelopmental Problems

Objective: The Quantified Behavioral Test (QbTest) is a computerized diagnostic test for ADHD, used in clinical psychiatric care, but its validity may be questioned. We analyzed the QbTest's diagnostic validity and its relation to cognitive ability and psychosocial factors in an adolescent population with a high occurrence of neurodevelopmental disorders. Method: In total, 340 participants aged 15 years, completed the QbTest, along with questionnaires, clinical and intelligence quotient (IQ) assessments. Results: The clinical assessment resulted in 89 (26%) participants with ADHD. Area under curve (AUC) scores indicated a random to poor validity of the QbTest (AUC range = 0.48-0.64). QbTest scores of inattention and impulsivity correlated with IQ. Conclusion: The QbTest was insufficient as a diagnostic test for ADHD, and was not able to differentiate ADHD from other neurodevelopmental conditions. Clinicians should be aware of the dubious discriminating power of the QbTest.

A Within-Sample Comparison of Two Innovative Neuropsychological Tests for Assessing ADHD

New innovative neuropsychological tests in attention deficit hyperactivity disorder ADHD have been proposed as objective measures for diagnosis and therapy. The current study aims to investigate two different commercial continuous performance tests (CPT) in a head-to-head comparison regarding their comparability and their link with clinical parameters. The CPTs were evaluated in a clinical sample of 29 adult patients presenting in an ADHD outpatient clinic. Correlational analyses were performed between neuropsychological data, clinical rating scales, and a personality-based measure. Though inattention was found to positively correlate between the two tests (r = 0.49, p = 0.01), no association with clinical measures and inattention was found for both tests. While hyperactivity did not correlate between both tests, current ADHD symptoms were positively associated with Nesplora Aquarium’s motor activity (r = 0.52 to 0.61, p < 0.05) and the Qb-Test’s hyperactivity (r = 0.52 to 0.71, p < 0.05). Conclusively, the overall comparability of the tests was limited and correlation with clinical parameters was low. While our study shows some interesting correlation between clinical symptoms and sub-scales of these tests, usage in clinical practice is not recommended.

A hybrid AI approach for supporting clinical diagnosis of attention deficit hyperactivity disorder (ADHD) in adults

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness. It is considered as an important public health issue and prevalence of, as well as demand for diagnosis, has increased as awareness of the disease grew over the past years. Supply of specialist medical experts has not kept pace with the increasing demand for assessment, both due to financial pressures on health systems and the difficulty to train new experts, resulting in growing waiting lists. Patients are not being treated quickly enough causing problems in other areas of health systems (e.g. increased GP visits, increased risk of self-harm and accidents) and more broadly (e.g. time off work, relationship problems). Advances in AI make it possible to support the clinical diagnosis of ADHD based on the analysis of relevant data. This paper reports on findings related to the mental health services of a specialist Trust within the UK’s National Health Service (NHS). The analysis studied data of adult patients who underwent diagnosis over the past few years, and developed a hybrid approach, consisting of two different models: a machine learning model obtained by training on data of past cases; and a knowledge model capturing the expertise of medical experts through knowledge engineering. The resulting algorithm has an accuracy of 95% on data currently available, and is currently being tested in a clinical environment.

Transcranial Direct Current Stimulation in ADHD: A Systematic Review of Efficacy, Safety, and Protocol-induced Electrical Field Modeling Results

Transcranial direct current stimulation (tDCS) is a promising method for altering cortical excitability with clinical implications. It has been increasingly used in neurodevelopmental disorders, especially attention-deficit hyperactivity disorder (ADHD), but its efficacy (based on effect size calculations), safety, and stimulation parameters have not been systematically examined. In this systematic review, we aimed to (1) explore the effectiveness of tDCS on the clinical symptoms and neuropsychological deficits of ADHD patients, (2) evaluate the safety of tDCS application, especially in children with ADHD, (3) model the electrical field intensity in the target regions based on the commonly-applied and effective versus less-effective protocols, and (4) discuss and propose advanced tDCS parameters. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach, a literature search identified 14 empirical experiments investigating tDCS effects in ADHD. Partial improving effects of tDCS on cognitive deficits (response inhibition, working memory, attention, and cognitive flexibility) or clinical symptoms (e.g., impulsivity and inattention) are reported in 10 studies. No serious adverse effects are reported in 747 sessions of tDCS. The left and right dorsolateral prefrontal cortex are the regions most often targeted, and anodal tDCS the protocol most often applied. An intensity of 2 mA induced stronger electrical fields than 1 mA in adults with ADHD and was associated with significant behavioral changes. In ADHD children, however, the electrical field induced by 1 mA, which is likely larger than the electrical field induced by 1 mA in adults due to the smaller head size of children, was sufficient to result in significant behavioral change. Overall, tDCS seems to be a promising method for improving ADHD deficits. However, the clinical utility of tDCS in ADHD cannot yet be concluded and requires further systematic investigation in larger sample sizes. Cortical regions involved in ADHD pathophysiology, stimulation parameters (e.g. intensity, duration, polarity, and electrode size), and types of symptom/deficit are potential determinants of tDCS efficacy in ADHD. Developmental aspects of tDCS in childhood ADHD should be considered as well.

FACT: a randomised controlled trial to assess the feasibility of QbTest in the assessment process of attention deficit hyperactivity disorder (ADHD) for young people in prison-a feasibility trial protocol

INTRODUCTION

The prevalence of attention deficit hyperactivity disorder (ADHD) within the Children and Young People Secure Estate (CYPSE) is much higher than seen in the general population. To make a diagnosis of ADHD, clinicians draw on information from multiple sources, including parents and teachers. However, obtaining these is particularly difficult for young people in the secure estate. There is increasing evidence in the community that QbTest is able to assist in the accurate and earlier diagnosis of ADHD. The objective of this study is to assess the feasibility and acceptability of QbTest in the assessment of ADHD within the CYPSE.

METHODS AND ANALYSIS

A single-centre parallel group feasibility randomised controlled trial will be conducted. Sixty young people within the CYPSE identified as displaying possible symptoms of ADHD will be randomised to the intervention arm (n=30; QbTest plus usual care) or control arm (n=30; usual care). Primary analyses will be descriptive and a process evaluation will be conducted to assess the contexts involved in implementing the intervention. Interviews will be conducted to explore acceptability and thematic analysis will be used to analyse the data.

ETHICS AND DISSEMINATION

This study was approved by National Health Service Wales research ethics committee 3 (18/WA/0347) on 15 February 2019. The findings will be published in peer-reviewed journals, presented at relevant conferences and disseminated to the public via summaries cocreated with our patient and public involvement group.

TRIAL REGISTRATION NUMBER

ISRCTN17402196.

A Deep Learning Approach for Missing Data Imputation of Rating Scales Assessing Attention-Deficit Hyperactivity Disorder

A variety of tools and methods have been used to measure behavioral symptoms of attention-deficit/hyperactivity disorder (ADHD). Missing data is a major concern in ADHD behavioral studies. This study used a deep learning method to impute missing data in ADHD rating scales and evaluated the ability of the imputed dataset (i.e., the imputed data replacing the original missing values) to distinguish youths with ADHD from youths without ADHD. The data were collected from 1220 youths, 799 of whom had an ADHD diagnosis, and 421 were typically developing (TD) youths without ADHD, recruited in Northern Taiwan. Participants were assessed using the Conners' Continuous Performance Test, the Chinese versions of the Conners' rating scale-revised: short form for parent and teacher reports, and the Swanson, Nolan, and Pelham, version IV scale for parent and teacher reports. We used deep learning, with information from the original complete dataset (referred to as the reference dataset), to perform missing data imputation and generate an imputation order according to the imputed accuracy of each question. We evaluated the effectiveness of imputation using support vector machine to classify the ADHD and TD groups in the imputed dataset. The imputed dataset can classify ADHD vs. TD up to 89% accuracy, which did not differ from the classification accuracy (89%) using the reference dataset. Most of the behaviors related to oppositional behaviors rated by teachers and hyperactivity/impulsivity rated by both parents and teachers showed high discriminatory accuracy to distinguish ADHD from non-ADHD. Our findings support a deep learning solution for missing data imputation without introducing bias to the data.

Gender Differences in Objective and Subjective Measures of ADHD Among Clinic-Referred Children

Attention deficit hyperactivity disorder (ADHD), one of the most prevalent childhood disorders today, is generally more likely to be diagnosed and treated in boys than in girls. However, gender differences in ADHD are currently poorly understood, partly because previous research included only a limited proportion of girls and relied mainly on subjective measures of ADHD, which are highly vulnerable to reporter's bias. To further examine gender differences in ADHD and to address some of the shortcomings of previous studies, this study examined gender differences in subjective and objective measures of ADHD among clinic-referred children with ADHD. Participants were 204 children aged 6-17 years-old with ADHD (129 boys, 75 girls). A retrospective analysis was conducted using records of a clinical database. Obtained data included parent and teacher forms of the Conners ADHD rating scales, Child Behavior Checklist (CBCL), Teacher's Report Form (TRF), and child's continuous performance test (CPT) scores. Results showed that according to parents' and teachers' reports of ADHD-related symptoms (Conners ADHD rating scales), girls had more inattention problems than boys, but no differences were identified in the level of hyperactivity and impulsivity symptoms. CPT data, however, revealed higher impulsivity among boys. We did not find gender differences in the level of distractibility during CPT performance. Specifically, the effects of distractors type (visual environmental stimuli, auditory stimuli, or a combination of them) and distractors load (one or two distracting stimuli at a time) on CPT performance did not differ between boys and girls with ADHD. These findings suggest that gender effects on ADHD symptoms may differ between subjective and objective measures. Understanding gender differences in ADHD may lead to improved identification of girls with the disorder, helping to reduce the gender gap in diagnosis and treatment.

Biomarker Research in ADHD: the Impact of Nutrition (BRAIN) - study protocol of an open-label trial to investigate the mechanisms underlying the effects of a few-foods diet on ADHD symptoms in children

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is the most common childhood behavioural disorder, causing significant impediment to a child's development. It is a complex disorder with numerous contributing (epi)genetic and environmental factors. Currently, treatment consists of behavioural and pharmacological therapy. However, ADHD medication is associated with several side effects, and concerns about long-term effects and efficacy exist. Therefore, there is considerable interest in the development of alternative treatment options. Double-blind research investigating the effects of a few-foods diet (FFD) has demonstrated a significant decrease in ADHD symptoms following an FFD. However, an FFD requires a considerable effort of both child and parents, limiting its applicability as a general ADHD treatment. To make FFD intervention less challenging or potentially obsolete, we need to understand how, and in which children, an FFD affects ADHD behaviour and, consequently, the child's well-being. We hypothesise that an FFD affects brain function, and that the nutritional impact on ADHD is effectuated by a complex interplay between the microbiota, gut and brain, that is, the microbiota-gut-brain axis.

METHODS AND ANALYSIS

The Biomarker Research in ADHD: the Impact of Nutrition (BRAIN) study is an open-label trial with researchers blinded to changes in ADHD symptoms during sample processing and initial data analyses.

ETHICS AND DISSEMINATION

The Medical Research and Ethics Committee of Wageningen University has approved this study (NL63851.081.17, application 17/24). Results will be disseminated through peer-reviewed journal publications, conference presentations, (social) media and the BRAIN study website. A summary of the findings will be provided to the participants.

TRIAL REGISTRATION NUMBER

NCT03440346.

STUDY DATES

Collection of primary outcome data started in March 2018 and will be ongoing until 100 children have participated in the study. Sample data analysis will start after all samples have been collected.

Objective assessment of attention-deficit/hyperactivity disorder in older adults compared with controls using the QbTest

OBJECTIVES

Attention-deficit/hyperactivity disorder (ADHD) persists into old age, with prevalence rates of 2.8% to 3.3% in adults over 60 years of age. Most diagnostic assessment tools are not validated for older adults. The Quantified behavioral Test (QbTest) is an objective assessment for the core symptoms of ADHD and is validated for children and younger adults. We investigated whether the QbTest can be used to differentiate between older adults with ADHD and healthy controls.

METHODS

Older adults aged 55 to 79 years with (n = 97) or without (n = 112) ADHD were assessed with the QbTest. They also rated their ADHD symptom severity. QbTest raw scores were compared between groups. Factor scores were computed using factor loadings from a confirmatory factor analysis (CFA). Multilevel regressions were used to determine effects of background characteristics and comorbidity. Logistic regressions were performed to determine whether the QbTest differentiated between patients with ADHD and healthy controls.

RESULTS

The factor structure of the CFA was comparable with that of younger age groups. Older age was associated with higher Inattention score. Parameters comprising the factors Hyperactivity and Inattention, but not Impulsivity, were shown to contribute significantly in differentiating between the groups. The QbTest had a correct classification rate of 70%, which was increased to 91% when combining QbTest scores and self-reports of ADHD symptom severity.

CONCLUSIONS

The QbTest is feasible for older adults, and the factors Hyperactivity and Inattention are valid parameters for the diagnostic assessment of ADHD in older adults, when used in addition to self-reports.

The effects of practicing target-shooting sport on the severity of inattentive, hyperactive, and impulsive symptoms in children: a non-randomised controlled open-label study in Denmark

Purpose: Target-shooting sport requires mental effort and concentration. Training may reduce inattentiveness and distractibility. There is little knowledge if children with symptoms of attention-deficit/hyperactivity disorder (ADHD) benefit from practicing target-shooting sport. Materials and methods: Our study aims to investigate this in a non-randomised controlled open-label study of 128 children, 10-14 years of age, with ADHD-symptoms. The intervention-group (n = 64) practiced target-shooting in local shooting associations once a week for 6 months. The control group (n = 64) received treatment as usual. Primary outcome: teacher-rated ADHD-RS-IV-total score. Secondary outcomes: (a) parent-rated ADHD-RS-IV-total score; (b) teacher- and parent-rated Strengths-and-Difficulties-Questionnaire (SDQ); (c) self-rated quality of life (KIDSCREEN-27-total score); and (d) four objective measurements of ADHD-symptoms using the QbTest^™. The data were collected at baseline and after 6 months. Results: When estimating the marginal effect of the intervention on our primary outcome, the teacher-rated ADHD-RS-IV, we found no significant effect (mean change between groups (contrast)=2.23; p = 0.193). However, we did find significant beneficial effects on four of the eight secondary outcomes, including the parent-rated ADHD-RS-IV-total score (contrast = 4.76; p = 0.024), the parent-rated SDQ-total score (contrast = 2.09; p = 0.027), and on the QbTest^™ measurements of the Reaction Time Variation (RTVar) (contrast = 36.96; p = 0.013), and of Omission Errors (contrast = 7.57; p = 0.019). Conclusions: Despite the negative result on the primary outcome, the robust findings on these secondary outcomes in this open-label study indicate proof of concept that practicing target-shooting sport may have some beneficial effects on the severity of ADHD-symptoms in children. No adverse events were reported. Randomised trials of this non-pharmacological intervention are needed.

Clinical Validation of Eye Vergence as an Objective Marker for Diagnosis of ADHD in Children

OBJECTIVE

ADHD youth show poor oculomotor control. Recent research shows that attention-related eye vergence is weak in ADHD children.

METHOD

To validate vergence as a marker to classify ADHD, we assessed the modulation in the angle of vergence of children ( n = 43) previously diagnosed with ADHD while performing an attention task and compared the results with age-matched clinical controls ( n = 19) and healthy peers ( n = 30).

RESULTS

We observed strong vergence responses in healthy participants and weak vergence in the clinical controls. ADHD children showed no significant vergence responses. Machine-learning models classified ADHD patients ( n = 21) from healthy controls ( n = 21) with an accuracy of 96.3% (false positive [FP]: 5.12%; false negative [FN]: 0%; area under the curve [AUC]: 0.99) and ADHD children ( n = 11) from clinical controls ( n = 14) with an accuracy of 85.7% (FP: 4.5%; FN: 19.2%, AUC: 0.90).

CONCLUSION

In combination with an attention task, vergence responses can be used as an objective marker to detect ADHD in children.

Assessing ADHD symptoms in children and adults: evaluating the role of objective measures

BACKGROUND

Diagnostic guidelines recommend using a variety of methods to assess and diagnose ADHD. Applying subjective measures always incorporates risks such as informant biases or large differences between ratings obtained from diverse sources. Furthermore, it has been demonstrated that ratings and tests seem to assess somewhat different constructs. The use of objective measures might thus yield valuable information for diagnosing ADHD. This study aims at evaluating the role of objective measures when trying to distinguish between individuals with ADHD and controls. Our sample consisted of children (n = 60) and adults (n = 76) diagnosed with ADHD and matched controls who completed self- and observer ratings as well as objective tasks. Diagnosis was primarily based on clinical interviews. A popular pattern recognition approach, support vector machines, was used to predict the diagnosis.

RESULTS

We observed relatively high accuracy of 79% (adults) and 78% (children) applying solely objective measures. Predicting an ADHD diagnosis using both subjective and objective measures exceeded the accuracy of objective measures for both adults (89.5%) and children (86.7%), with the subjective variables proving to be the most relevant.

CONCLUSIONS

We argue that objective measures are more robust against rater bias and errors inherent in subjective measures and may be more replicable. Considering the high accuracy of objective measures only, we found in our study, we think that they should be incorporated in diagnostic procedures for assessing ADHD.

Study of user experience of an objective test (QbTest) to aid ADHD assessment and medication management: a multi-methods approach

BACKGROUND

The diagnosis and monitoring of Attention deficit hyperactivity disorder (ADHD) typically relies on subjective reports and observations. Objective continuous performance tests (CPTs) have been incorporated into some services to support clinical decision making. However, the feasibility and acceptability of adding such a test into routine practice is unknown. The study aimed to investigate the feasibility and acceptability of adding an objective computerised test to the routine assessment and monitoring of attention deficit hyperactivity disorder (ADHD).

METHODS

Semi-structured interviews were conducted with clinicians (n = 10) and families (parents/young people, n = 20) who participated in a randomised controlled trial. Additionally, the same clinicians (n = 10) and families (n = 76) completed a survey assessing their experience of the QbTest. The study took place in child and adolescent mental health and community paediatric clinics across the UK. Interview transcripts were thematically analysed.

RESULTS

Interviewed clinicians and families valued the QbTest for providing an objective, valid assessment of symptoms. The QbTest was noted to facilitate communication between clinicians, families and schools. However, whereas clinicians were more unanimous on the usefulness of the QbTest, survey findings showed that, although the majority of families found the test useful, less than half felt the QbTest helped them understand the clinician's decision making around diagnosis and medication. The QbTest was seen as a potentially valuable tool to use early in the assessment process to streamline the care pathway. Although clinicians were conscious of the additional costs, these could be offset by reductions in time to diagnosis and the delivery of the test by a Healthcare Assistant.

CONCLUSIONS

The findings indicate the QbTest is an acceptable and feasible tool to implement in routine clinical settings. Clinicians should be mindful to discuss the QbTest results with families to enable their understanding and engagement with the process. Further findings from definitive trials are required to understand the cost/benefit; however, the findings from this study support the feasibility and acceptability of integrating QbTest in the ADHD care pathway.

TRIAL REGISTRATION

The findings form the implementation component of the Assessing QbTest Utility in ADHD (AQUA) Trial which is registered with the ISRCTN registry ( ISRCTN11727351 , retrospectively registered 04 July 2016) and clinicaltrials.gov ( NCT02209116 , registered 04 August 2014).

Transcranial direct current stimulation improves clinical symptoms in adolescents with attention deficit hyperactivity disorder

Anodal transcranial direct current stimulation (tDCS) of the prefrontal cortex has repeatedly been shown to improve working memory. As patients with attention deficit hyperactivity disorder (ADHD) are characterized by both underactivation of the prefrontal cortex and deficits in working memory that correlate with clinical symptoms, it is hypothesized that the modulation of prefrontal activity with tDCS in patients with ADHD increases performance in working memory and reduces symptoms of ADHD. To test this hypothesis, fifteen adolescents with ADHD (12-16 years old, three girls and 12 boys) were treated according to the randomized, double-blinded, sham-controlled, crossover design with either 1 mA anodal tDCS over the left dorsolateral prefrontal cortex or with the sham protocol 5 days each with a 2 weeks pause between these conditions. Anodal tDCS caused a significant reduction in clinical symptoms of inattention and impulsivity in adolescents with ADHD compared to sham stimulation. The clinical effects were supported by a significant reduction in inattention and hyperactivity in a standardized working memory test (QbTest). The described effects were more pronounced 7 days after the end of stimulation, a fact which emphasizes the long-lasting clinical and neuropsychological changes after tDCS. This study provides the first evidence that tDCS may reduce symptoms of ADHD and improve neuropsychological functioning in adolescents and points on the potential of tDCS as a form of treatment for ADHD.

The clinical utility of the continuous performance test and objective measures of activity for diagnosing and monitoring ADHD in children: a systematic review

Attention-deficit hyperactivity disorder (ADHD) is typically diagnosed using clinical observation and subjective informant reports. Once children commence ADHD medication, robust monitoring is required to detect partial or non-responses. The extent to which neuropsychological continuous performance tests (CPTs) and objective measures of activity can clinically aid the assessment and titration process in ADHD is not fully understood. This review describes the current evidence base for the use of CPTs and objectively measured activity to support the diagnostic procedure and medication management for children with ADHD. Four databases (PsycINFO, Medline, Allied and Complementary Medicine (AMED), and PsycARTICLES) were systematically searched to understand the current evidence base for (1) the use of CPTs to aid clinical assessment of ADHD; (2) the use of CPTs to aid medication management; and (3) the clinical utility of objective measures of activity in ADHD. Sixty relevant articles were identified. The search revealed six commercially available CPTs that had been reported on for their clinical use. There were mixed findings with regard to the use of CPTs to assess and manage medication, with contrasting evidence on their ability to support clinical decision-making. There was a strong evidence base for the use of objective measures of activity to aid ADHD/non-ADHD group differentiation, which appears sensitive to medication effects and would also benefit from further research on their clinical utility. The findings suggest that combining CPTs and an objective measure of activity may be particularly useful as a clinical tool and worthy of further pursuit.

Factorial Structure and Validity of the Quantified Behavior Test Plus (Qb+©)

This study investigates the factorial structure and validity of the Quantified Behavior Test Plus (Qb+©), a computerized test to objectively evaluate the three attention deficit/hyperactivity disorder core symptoms, hyperactivity, inattention, and impulsivity, independently. Confirmatory and exploratory factor analyses were conducted with an outpatient sample of 773 subjects ≥12 years old. In a second sample of 297 patients ≥16 years, a multitrait–multimethod analysis was performed to examine concurrent and discriminant validity. The discriminative power of the Qb+ was investigated using a general linear model and logistic regression analysis. The three factorial structure (Hyperactivity, Inattention, Impulsivity) was verified in the confirmatory factor analysis. Fit indices demonstrated a good model fit and factor loadings were almost all moderate to high. In the multitrait–multimethod analysis, the criterion for convergent validity was fulfilled. The discriminant validity of the Qb+ was partially supported. Significant but small gender and age effects were found. In the logistic regression analysis, omission errors and reaction time variability, belonging to the Inattention factor, were able to discriminate between subjects with and without attention deficit/hyperactivity disorder. The internal structure of the Qb+ was verified. Its validity was partially supported. Results regarding discriminative power were mixed.

Protocol investigating the clinical utility of an objective measure of activity and attention (QbTest) on diagnostic and treatment decision-making in children and young people with ADHD-'Assessing QbTest Utility in ADHD' (AQUA): a randomised controlled trial

INTRODUCTION

The National Institute for Health and Care Excellence (NICE) guidelines for attention deficit/hyperactivity disorder (ADHD) state that young people need to have access to the best evidence-based care to improve outcome. The current 'gold standard' ADHD diagnostic assessment combines clinical observation with subjective parent, teacher and self-reports. In routine practice, reports from multiple informants may be unavailable or contradictory, leading to diagnostic uncertainty and delay. The addition of objective tests of attention and activity may help reduce diagnostic uncertainty and delays in initiating treatment leading to improved outcomes. This trial investigates whether providing clinicians with an objective report of levels of attention, impulsivity and activity can lead to an earlier, and more accurate, clinical diagnosis and improved patient outcome.

METHODS AND ANALYSIS

This multisite randomised controlled trial will recruit young people (aged 6-17 years old) who have been referred for an ADHD diagnostic assessment at Child and Adolescent Mental Health Services (CAMHS) and Community Paediatric clinics across England. Routine clinical assessment will be augmented by the QbTest, incorporating a continuous performance test (CPT) and infrared motion tracking of activity. The participant will be randomised into one of two study arms: QbOpen (clinician has immediate access to a QbTest report): QbBlind (report is withheld until the study end). Primary outcomes are time to diagnosis and diagnostic accuracy. Secondary outcomes include clinician's diagnostic confidence and routine clinical outcome measures. Cost-effective analysis will be conducted, alongside a qualitative assessment of the feasibility and acceptability of incorporating QbTest in routine practice.

ETHICS AND DISSEMINATION

The findings from the study will inform commissioners, clinicians and managers about the feasibility, acceptability, clinical utility and cost-effectiveness of incorporating QbTest into routine diagnostic assessment of young people with ADHD. The results will be submitted for publication in peer-reviewed journals. The study has received ethical approval.

TRIAL REGISTRATION NUMBER

NCT02209116.

Slow cortical potential neurofeedback and self-management training in outpatient care for children with ADHD: study protocol and first preliminary results of a randomized controlled trial

Background: Treatment for children with attention deficit/hyperactivity disorder (ADHD) today is predominantly pharmacological. While it is the most common treatment, it might not always be the most appropriate one. Moreover, long term effects remain unclear. Behavior therapy (BT) and non-pharmacological treatments such as neurofeedback (NF) are promising alternatives, though there are no routine outpatient care/effectiveness studies yet that have included children with medication or changes in medication.

Methods/design: This paper presents the protocol of a randomized controlled trial to compare the effectiveness of a Slow Cortical Potential (SCP) NF protocol with self-management (SM) in a high frequent outpatient care setting. Both groups (NF/SM) receive a total of 30 high frequent therapy sessions. Additionally, 6 sessions are reserved for comorbid problems. The primary outcome measure is the reduction of ADHD core symptoms according to parent and teacher ratings.

Preliminary Results: Untill now 58 children were included in the study (48 males), with a mean age of 8.42 (1.34) years, and a mean IQ of 110 (13.37). Conners-3 parent and teacher ratings were used to estimate core symptom change. Since the study is still ongoing, and children are in different study stages, pre-post and follow-up results are not yet available for all children included. Preliminary results suggest overall good pre-post effects, though. For parent and teacher ratings an ANOVA with repeated measures yielded overall satisfying pre-post effects (η² 0.175–0.513). Differences between groups (NF vs. SM) could not yet be established (p = 0.81).

Discussion: This is the first randomized controlled trial to test the effectiveness of a NF protocol in a high frequent outpatient care setting that does not exclude children on or with changes in medication. First preliminary results show positive effects. The rationale for the trial, the design, and the strengths and limitations of the study are discussed.

Trial registration: This trial is registered in www.clinicaltrials.gov as NCT01879644.

Preliminary evidence for altered motion tracking-based hyperactivity in ADHD siblings

Background

It is well-established that ADHD children have deficits in executive functions such as performance variability and sustained attention. It has been suggested that these deficits are intermediate phenotypes. Hyperactivity, a core symptom of ADHD, has not yet been explored as a potential intermediate phenotype in ADHD. The computerized Quantified behavior Test (QbTest) is a combined continuous performance and activity test that assesses hyperactivity, inattention, and impulsivity separately. The aim of the present study was to (1) investigate the utility of objectively measured motor activity as a potential intermediate phenotype in ADHD, and (2) explore intermediate phenotypes for ADHD at the factor instead of single variable level.

Method

Forty-five ADHD children, 22 non-affected siblings, and 45 unrelated controls with no family history of ADHD performed the QbTest. Effects of familiality as well as influences of age and gender on QbTest symptom dimensions were tested.

Results

ADHD children showed the greatest impairments on all three QbTest factors, followed by their non-affected siblings, with control children showing the lowest scores. Group differences between the non-affected siblings and controls were only significant for the motion tracking-based Hyperactivity factor. Results were independent of age and gender.

Conclusion

Hyperactivity assessed by a motion tracking system may be a useful intermediate phenotype in ADHD. Prospective research should use larger samples to further examine the QbTest factors, especially the motion tracking-based Hyperactivity factor which may be a candidate for an intermediate phenotype in ADHD.