A test which can offer a more accurate diagnosis of ADHD in children and therefore reduce the prescription of unnecessary medications is an appealing prospect, particularly as 66% of children in the US who receive a diagnosis currently take medication. This is what a new screening tool that has been approved by the FDA is promising to do. However, rather than taking into account the full clinical picture, the Neuropsychiatric EEG-Based Assessment Aid (NEBA), as the name suggests, measures someone’s brain waves; lasting around quarter of an hour, electrodes are placed on a child’s head to measure their brain activity. This is based on findings that, in general, a child with ADHD does not have the same pattern of brainwaves as someone without the condition; the ratio of theta and beta waves is reported to be higher in youngsters with ADHD, which may explain their altered focus and attention. However, is this information really sufficient to be able to make a diagnosis?
Simplifying a complex diagnosis
Concerns have been raised that the development of this new tool will lead to an over-reliance on the device for the diagnosis of ADHD and that it may try to simplify what is a complex diagnosis, with time-poor physicians using this without gathering the necessary background information or referring on to a specialist. Rahn Bailey, who is the National Medical Association’s president, spoke of being “cautiously optimistic” about the device, but warned that no matter what technological advances there are, a diagnosis should always be based on clinical decision-making, considering all the information available. His thoughts are echoed by the fact that the FDA has approved that the NEBA device can only be marketed for use in conjunction with medical and psychological assessment of ADHD, so that its use does not replace clinical evaluation; it would merely help to inform the decision.
Too small and narrow a sample
Although accuracy in the diagnosis may have increased from 61% to 88% when NEBA was used, the study itself has been called into question with regards to both sample size and diversity. While the clinical study for the device met the standards set out by the FDA, it only involved 275 children and just 17% of children in the study were African-American. However, according to CDC figures, rates of ADHD are nearly as high amongst African-American children as those who are white, so this should have been reflected more accurately in those participating in the study. The findings indicated that the accuracy of diagnosis was lower in African-American children (85% compared to 90% among white children), so without adequate diversity in the study it is difficult to know whether the electrical activity in the brain in ADHD is similar across different ethnic groups. As African-American children are already at a disadvantage with regards to receiving a diagnosis and treatment for ADHD, use of this device if it could not accurately provide a diagnosis, could simply lead to further inequalities.
An unnecessary and costly test
Parents may have read about the measurements of brainwaves to diagnose epilepsy, but while that has a clear neurological basis, ADHD is complex disorder with a behavioral basis, so diagnosis is not straightforward. It is important that parents are therefore aware of the NEBA device’s limitations, as receiving the test may be costly in more ways than one if it fails to meet their expectations. It cannot provide a definitive diagnosis of ADHD, as this needs to take into account symptoms, functional impairment and what impact this has, which the device can provide no information on. There is also no real evidence that use of the device can reduce the number of false positive diagnoses; in the study it improved overall accuracy of diagnosis, but what this translates to in clinical practice remains to be seen. While these are the two most likely reasons for their interest in pursuing the test, parents are therefore best advised to seek the help of a child psychiatrist or psychologist if they suspect their child has ADHD. This way using more conventional methods, a comprehensive assessment can be performed and individually tailored advice provided on diagnosis of ADHD, or alternatively on another condition if that is the conclusion. As yet it is also unclear as to whether NEBA can differentiate between ADHD and say a disorder of mood or a learning disability, which is another reason why specialist assessment is needed to ensure the correct diagnosis is reached.
While some see NEBA as a breakthrough owing to the increasing number of cases of ADHD, what we really need is greater access to mental health services, rather than the development of technological devices.