Integrating objective ADHD tests into your clinical pathway

Making changes to your ADHD care pathway can be positive for both your clinic and patients. An effective pathway can reduce inefficiencies and improve patient experience. In this guide, we answer some of the common questions you may have about introducing objective ADHD tests to your clinical pathway. The guide will cover resourcing, integration with subjective measures, and more.

When should you review your ADHD care pathway?

Sometimes, ADHD clinical pathways go unchanged for years and inefficiencies can creep in. If your pathway has not been critically reviewed recently, or you are considering introducing objective tests, it could be a good idea to review your pathway.

Where in the pathway should you integrate objective tests?

Clinics can take different approaches, however, for initial evaluation, integrating objective tests towards the start of the pathway is beneficial.

• In the UK: The evaluation for the Focus ADHD National Programme suggests that placing objective testing towards the start of the pathway is beneficial. Here it can counterbalance subjective measures and support effective signposting, enabling clinicians to get the most from the consultation. By looking at the combined results of objective tests and subjective measures at the start of the evaluation process, clinicians have a strong evidence basis to work with.
• If a diagnosis other than ADHD is reached, then patients could be transferred to another pathway without completing further ADHD evaluations. This can reduce the total number of appointments required, shorten pathways, and free up valuable capacity that can be redirected towards waiting lists and post-diagnostic work.
• In the US: Approaches may need slight moderation based on insurance reimbursement and your clinic’s individual process. It is clinically recommended to use objective testing during initial evaluation, alongside rating-scales and clinical interviews to provide a comprehensive review to determine a patient diagnosis.

If the patient receives an ADHD diagnosis, objective testing can then be used to measure and optimize treatment response at follow-ups.

Visualization of how objective tests can be integrated into ADHD pathways

How does objective testing work with other ADHD evaluation measures?

Objective tests are not intended as a standalone test for ADHD. Instead, they are intended to be used alongside subjective measures to give healthcare providers a more complete assessment of symptoms to help support clinical decision-making.

Will objective testing add additional steps or delays to the pathway?

Studies including the East Midlands Health Innovation Network’s real-world evaluation have found that integrating objective testing for ADHD can reduce the number of evaluations and time taken to make a formal ADHD diagnosis. A nurse-led multi-disciplinary team model for ADHD also found that when they introduced objective testing, their three-year waiting list was brought down to 12 weeks with existing staff.

Humphreys and Sitton-Kent report on a widespread real-world application of objective test QbTest within three NHS Trusts and covering 1,250 children. They found that the average number of days to reach a diagnostic decision decreased from a range of 161 – 453 days to a range of 15 to 252 days.

Integrating objective testing into clinical ADHD pathways is becoming a more widespread and standardized response to the challenges of ADHD diagnosis. The Focus ADHD National Evaluation report concluded that there was clinical utility in embedding QbTest as standard practice within ADHD care pathways in NHS pediatric services.

What are the resource implications of integrating objective testing?

A study by Hall et al. (2016) found that the majority of healthcare professionals felt the objective test (QbTest) was best administered by a trained healthcare assistant, with the results then interpreted by the clinician. This means the test can be completed without impacting clinicians’ time. Administering an objective test is very quick and can take as little as 15-20 minutes for the patient to complete (overseen by the healthcare assistant).

Survey data collected in the Focus national program evaluation suggested that school visits can take four hours and are associated with additional travel costs. By comparison, multiple objective tests could be completed in-clinic within the same timeframe, whilst allowing a window of opportunity for observation of the patient while they engage with the task.

Whilst clinicians will need to analyze results, studies have indicated that there is a direct time saving from reductions in some subjective measures, such as school observations. McKenzie et al. (2022) report a reduction in school observations between 17% and 22% after implementing objective testing.

The NICE Medtech innovation briefing [MIB318] reports a reduction in clinician assessment time of 20% to 30% following the introduction of objective testing.

What are the potential benefits of introducing objective ADHD testing to my clinic?

Detailed insights into ADHD symptoms

ADHD is a complex condition and symptoms such as inattention can present in other conditions such as depression, anxiety, autism, or sleep disorders. An objective test does more than simply indicate the presence or absence of inattention, hyperactivity, and impulsivity. The data can help to identify the clinical significance of symptomology, as well as patterns in symptom behavior, all of which can help to aid diagnosis.

Increased clinician confidence

Subjective tests are simply that – subjective. They are vulnerable to symptom masking and misreporting by patients, family members, or school staff. Growing awareness of symptoms and the condition, including from unreliable sources such as social media, may also lead to overreporting in subjective assessments. An objective test uses observed data and can lead to greater clinician confidence when making a diagnosis.

This is supported by the national program evaluation, and in a 2018 study by Hollis which reports that 94% of clinicians agree that “clinical confidence is increased” when a QbTest report is available to them.

Improved patient experience

Widespread adoption of objective testing leads to a more equitable and consistent experience for patients, regardless of geography.

Ability to compare ADHD test results

Objective test results (such as those for QbTest) are benchmarked against same-age and same-sex individuals without ADHD, allowing clear comparisons to aid diagnostic decision-making used together with other clinical measures.

Strong evidence base for ADHD diagnosis

Data from objective tests can be useful evidence if patients challenge or contest a diagnosis that rules out ADHD.

Improved efficiency of the care pathway

The National Institute for Clinical Excellence’s (NICE) Medtech innovation briefing [MIB318] reports that ‘The use of QbTest could improve the efficiency and speed of ADHD diagnosis as well as reduce assessment costs without loss of diagnostic accuracy.’

Reduction in the number of ADHD appointments

The Focus ADHD National Programme evaluation concludes that implementing QbTest alongside subjective measures ‘reduced the number of clinical appointments needed to reach a diagnostic decision of ADHD.’

Want to find out more about introducing objective ADHD testing at your clinic?

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