Demonstrating efficiencies in ADHD pathways – A QbTest case study

1-minute summary

The neurodevelopmental service at Achieving for Children introduced QbTest as a one-year pilot program to evaluate efficiencies. QbTest is a computer-based performance task used to assess the three main areas of ADHD to aid assessment. Achieving for Children recruited an assistant psychologist to manage the project.

The clinical team collected quantitative data, comparing the number of appointments within the ADHD assessment pathway before and after the implementation of QbTest, the number of school observations, along with additional data. Results showed:

• • 82% reduction in school observations
  • 34% reduction in the number of appointments needed to reach a diagnosis
  • 88% of clinicians reported increased confidence in giving a diagnosis
  • 88% agreed that QbTest should be used routinely as part of the ADHD assessment

About Achieving for Children

The Royal Borough of Kingston and the London Borough of Richmond created Achieving for Children (AfC), a not-for-profit social enterprise in 2014. They hope to provide children’s services like assessment of ADHD and autism and promote children’s mental and emotional health as a tier 2 service. The Emotional Health Service (EHS) provides children’s mental health services locally, commissioned by the Integrated Care Board (ICB) to deliver a pathway for the assessment of autism or ADHD.

In March 2023, their neurodevelopmental service added QbTest under a 1-year pilot program as standard for all children and young people (CYP) on the ADHD pathway. Associate Director Emotional Health Service and Consultant Clinical Psychologist, Dr. Jo Steer and Assistant Psychologist, Ciaran Harte explore the many ways in which QbTest impacted the process of ADHD assessments within the service.

Introduction of QbTest to the AfC pathway

For a variety of different reasons, the service introduced QbTest. Some of these include:

• To provide a more efficient assessment process when used alongside other clinical measures
• To reduce the number of school observations
• To contribute to the quality and reliability of the assessment process (e.g., increase diagnostic confidence for clinicians)
• To assist in the neurodevelopmental screening process
• To assist in differential diagnosis (i.e., ADHD vs ASD)
• To increase objectivity of assessment and support patient understanding

Improving the quality and reliability of ADHD assessments

Prior to introducing QbTest into their pathway, Ciaran explains that there were a large number of school observations that they would partake in. This often led to a long wait time between an assessment and diagnosis. The introduction of QbTest, saw a reduction of 66% from first appointment to diagnosis.

The diagnostic reports at AfC suggest that the integration of QbTest added an objective element to their assessments which staff valued; with 88% of clinicians saying that having QbTest increased their confidence in giving a diagnosis, and agreeing that QbTest should be used routinely as part of the diagnostic assessment. Additionally, 100% of clinicians confirmed that QbTest was easy to incorporate into the assessment process.

“In an ideal world, it would be great if everyone coming for an ADHD assessment had QbTest integrated into [their] assessment process, as I think it makes the whole process much more robust. It increases clinician confidence, it gives us some really helpful data also at the same time, I see the value in using it further back up the pathway, particularly when school evidence is lacking or isn’t very strong.”

– Dr. Jo Steer, Associate Director Emotional Health Service

Addressing ADHD symptoms in younger people

School observations are one of the most common ADHD assessment methods for children since they can be a critical adjunct to parent and teacher reports. Despite its benefits, organizing a school observation comes with some challenges.

“With school observations, [children] engage differently with different subjects which is a challenge. The [QbTest] assessments are  more standardized [when compared to school observations] and I think it’s an extra piece of information that adds to the confidence of the clinician [owing to the] addition of objective evidence.”

– Ciaran Harte

The AfC team reported that they would have to conduct school observations as school forms would frequently not report the presence of ADHD adequately. AfC informed these visits to be time intensive, requiring coordination with the school and often taking a couple of months to coordinate, complete and write up. In the six months prior to the induction of QbTest, Ciaran completed 22 school observations.

Since the introduction of QbTest this has been reduced to four school observations, a reduction of 82%.

“When we observe a child during a QbTest it can be really helpful as it is a time and a setting which requires concentration and focus, because when we go into school to do an observation, children can be at play or be engaged in an activity that doesn’t demand too much concentration, or be engaged in an activity they’re really interested in. We might see a child with amazing concentration because perhaps they’re hyper focused and really doing well in such settings, creating a bigger challenge with school observations.”

– Dr. Jo Steer

Symptom masking in girls

ADHD presents itself differently in boys and girls. ADHD is thought to be under-recognized in girls and women mainly due to symptom masking. Jo mentions that in younger girls, the school reports are less reliable, perhaps owing to the school not noticing symptoms. The girl or the parents, at times, report concerns that the school may be overlooking certain behaviors. Girls typically go under the radar in cases where they do not present with hyperactivity but do with inattention.

An objective ADHD test can help see whether the girl meets the criteria for ADHD.

“In a school setting, it can be quite challenging to pick up on signs. We could go and sit in a classroom and observe a girl and not necessarily be picking up any difficulties, but may be able to pick up those better in a Qb [QbTest] setting. Girls work really hard to mask symptoms to fit in socially, so observing them in that social setting might not be helpful.”

– Dr. Jo Steer

Clinical effectiveness and efficiency of assessments

As part of their evaluation, AfC conducted a survey amongst clinicians within the Emotional Health Service. Here’s what they found about their experience using QbTest as part of the ADHD pathway:

• QbTest was easy to implement in their practice
• Results from QbTest were helpful in understanding their client’s symptoms
• Allowed for improved communication with patients

Clinicians found most benefit in cases where there was limited screening evidence available to put a young person forward for a full ADHD assessment. Situations where evidence was lacking, or where symptoms may be masked in the school environment are few examples.

I used it as a way of gathering objective information for the intake process. When a [young person’s] current school offered no/limited evidence for ADHD but the previous school, young person, family feedback and my observations at the choice and choice plus [intake assessments] were contrary to this. The Qb [QbTest] when offered, felt very validating to the young person and parents, they talked about feeling heard and listened to.”

Another reported that QbTest had been particularly useful “in cases where there is no second setting and in cases where families report symptoms of ADHD but the school does not see those symptoms or vice versa.”

Reports by AfC indicated a reduction of 34% in the number of clinical appointments required to make an ADHD diagnosis after the pilot. This indicates that QbTest has provided data that allowed clinicians to come to decisions with greater efficacy. This will have contributed to a reduction in waiting and assessment times overall for families and CYP.

Improving patient dialogue with QbTest

QbTest reports are visual and help facilitate communication with patients and families. The one thing that Jo says she likes about the QbTest report is its graphic element. She states that the clear visual presentation of the hyperactivity graph and the comparison with age and sex-matched norm groups makes it easier to share them with clients.

“Since results are broken down by quarter, you see potentially how hyperactivity is increasing the longer the test goes, and looking at the [omission and commission errors] helps us explain the diagnosis to families and schools.”

– Dr. Jo Steer

Previously the team relied solely on subjective measures such as clinical interviews, rating scales, and school observations, or feedback. Adding objective elements, backed by evidence, has been helpful in elevating the ADHD assessment process.

Disclaimer: Achieving for Children is commissioned to take single diagnosis cases that are indicated at screening as being ADHD or autism spectrum disorder. The sample for the evaluations above only included young people where a singular ADHD assessment took place. 

QbTest helps save clinicians time and improve the quality of care patients receive. Learn about how nurses are rethinking ADHD care in the NHS.

Add QbTest to your clinic’s pathway

QbTest is an objective test that measures the three core symptoms of ADHD – hyperactivity, impulsivity, and inattention. It standardizes ADHD pathway by using normative data of the same sex and age. It improves clinical understanding of patient symptoms and aids clinical decision making when used alongside other clinical measures.