Researchers Attempt to Create Objective Diagnostic Test for ADHD
Attention-deficit hyperactivity disorder (ADHD) is one of the most common behavioral disorders in the U.S. and the world. Although adults can have ADHD, it’s typically diagnosed between the ages of 3 and 12. In children, teens, and adults, the disorder is characterized by an impaired ability to focus attention, impaired or attenuate ability to control impulses, and excess activity, a.k.a. hyperactivity.
Behavioral scientists identify three types of ADHD. The type of ADHD is determined by the nature of symptoms displayed:
1. ADHD/Inattentive Presentation:
This type is defined – as indicated by its name – by inattention. Individuals find it difficult to complete tasks and pay attention to specific details. They may have problems following multi-step instructions or staying engaged on one topic of conversation. They get distracted easily and often forget to accomplish simple aspects of daily routines. For students, this can mean forgetting to turn in assignments after completing them, forgetting to do homework assignments, or missing details/specific instructions on class assignments or tests.
2. ADHD/Hyperactive-Impulsive Presentation:
This type is defined by excess physical activity. Individuals find it hard to sit still, and when sitting still, they fidget frequently. Younger individuals will run, climb, or jump constantly, if given the opportunity. Individuals of any age with this type of ADHD have problems controlling impulses. They may grab things from others, interrupt others during conversation, or speak out of turn, i.e. during a lecture given by a teacher or professor. They have problems waiting their turn or waiting while listening to directions. For students, this type of ADHD can result in disciplinary problems at school as well as academic difficulties.
3. ADHD/Combined:
An individual with ADHD/combined displays relatively equivalent amounts of the symptoms common to ADHD/inattentive and ADHD/hyperactive-impulsive.
It’s easy to see, based on the symptoms associated with the three types of ADHD we list above, how ADHD can cause significant problems for children, teens, and adults. We’ll focus on children and teens in this article, but it is important to understand that ADHD doesn’t go away once a person turns 18. The symptoms may change over the years, but the underlying disorder rarely, if ever, disappears completely.
How Treatment and Diagnosis for ADHD Works
In order to live with this developmental/behavioral disorder, people with ADHD learn to manage their symptoms in a way that best suits their individual characteristics. They develop personalized skills to support their academic, employment, and life goals.
Before receiving evidence-based treatment and support to get them to that place, however, they need an accurate diagnosis.
That’s what this article is about: a research effort conducted in Spain with the goal of developing an objective testing protocol to ensure accurate ADHD diagnoses that includes both the severity and type of ADHD present in an individual.
The current method of diagnosing ADHD is threefold:
- Teachers complete observational questionnaires and score individuals on what they see.
- Parents complete observational questionnaires and score their children on what they see.
- Doctors, psychiatrists, and therapists/counselors administer a range of biological, psychological, neurological, and physical tests and tabulate/cross-reference results with a detailed medical history of the individual.
During any consultation and/or testing time spent with an individual, doctors, psychiatrists, and therapists/counselors observe the behavior of the individual they test/assess. Their observations become part of the process and influence the final diagnosis.
The various professionals who participate in this process do their best to be objective. It’s clear, though, that the observational and scoring aspect of ADHD diagnosis introduces a subjective element – which is not entirely a bad thing. For instance, a child may perform assessments perfectly, but in an office meeting with a therapist, they may display classic and unmistakable ADHD symptoms. The assessing professional includes this behavior in their diagnostic decision, which is a good thing.
However, studies cited by the Spanish research team highlight the need for an objective component to ADHD testing.
ADHD: Toward Objective Diagnosis
Two recent studies – one involving over 450 psychotherapists and another involving teachers, parents, and caregivers – showed the potential flaws in the subjective nature of current ADHD tests. Data showed that among these parents and professionals, experienced in working and interacting with adolescents on a daily basis, diagnostic mistakes were common. The study revealed:
- 15% of the psychotherapists returned false positive diagnoses during in-person screenings
- 20% of the psychotherapists returned false negatives when using medical records and/or analyzing parent or teacher questionnaires to arrive at a diagnosis
- Young female teachers provided consistently high ADHD scores compared to baseline
- Older male teachers provided consistently low ADHD scores compared to baseline
- Current mood often influences parent and caregiver evaluations and scoring
The research team in Spain came up with a novel approach to help eliminate or reduce the phenomenon of false positives and negatives in ADHD testing: they decided to use a video game.
The game they chose is in a genre called endless runner games. Typically, these games can go on forever – literally. However, researchers trimmed this version down to seven minutes. In this game, the player – i.e. the person being assessed for ADHD – controls a cute, kid-friendly running racoon that has to jump over various obstacles along the running route. The player must hit a key, switch, or button on a joystick to jump the obstacles and avoid falling into holes.
Here’s how one of the researchers describe the concept:
“We hypothesize that children diagnosed with ADHD inattentive subtype will make more mistakes by omission and will jump closer to the hole as a result of the symptoms of inattention.”
To measure the presence of inattention objectively, computers calculate the avatar’s proximity to the obstacle when the player triggers the jump. The closer to the obstacle, the more inattentive the player. The good thing about the test is the mathematical nature of the metric. The time at which a player triggers each jump is objectively quantifiable. Therefore, it may be a way to indicate not only the presence of inattention, but also the severity of inattention.
The Running Racoon: Experimental Results
To test the game as a diagnostic tool, researchers recruited 32 children diagnosed with ADHD to play the game. While the children played the game, a licensed psychotherapist scored their behavior using one of the standard ADHD testing tools. For this experiment, they used the Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior rating scale. Mental health professionals know this test as The SWAN Scale.
To determine efficacy, researchers compared the SWAN scores to the video game inattention scores. They measured the median range to the obstacle when a player triggered the jump, the interquartile range to the obstacle when a player triggered the jump, and the number of jumps they player missed during the game.
Here’s what they found:
Median Range:
Scores strongly correlated with SWAN scales scored by a psychotherapist.
Interquartile Range (which is a statistical way to clarify a true median range):
Scores strongly correlated with SWAN scales scored by a psychotherapist.
Missed Jumps:
Scores strongly correlated with the severity of inattention determined by the scoring psychotherapist.
The researchers consider these strong correlations as evidence that their test can work, and has several advantages over other tests. These advantages include:
- It’s a game kids enjoy, most are already familiar with, and requires no special software or equipment. The testing game can run on any average PC or smart mobile device.
- It’s short. The entire test takes seven minutes. The duration of some of the clinical assessment tools creates problems for some kids. The longer the test runs, the worse their performance gets, which can skew results.
- It introduces and objective measure of severity. The number of missed jumps and the distance/time from the obstacle at which the player triggers a jump makes severity quantifiable.
This new test has the potential to be a positive step forward in ADHD diagnostic methods. While the subjective input of professionals helps diagnosis, the introduction of objective criteria can further help them ensure an accurate, evidence-based assessment of ADHD symptoms.
When a child or teen receives an accurate diagnosis the first time, they can then receive and participate in targeted, personalized treatment. An accurate diagnosis can reduce time spent pursuing mismatched treatments, which are time-consuming and expensive. An accurate initial diagnosis allows them to get started right away and develop the skills they need to manage the symptoms of their disorder. These skills support their ongoing academic and personal goals, and contribute overall success and well-being throughout adolescence and into adulthood.