Michael Walsh is a Clinical Nurse Specialist for HSE South and South Wexford Child and Adolescent Mental Health Service with extensive experience working with patients being assessed and treated for a range of mental health and neurodevelopmental conditions including ADHD.
Like many healthcare services globally, they are under pressure to support as many patients as possible whilst consistently delivering the highest standards of care. As Michael goes on to explain, tools like QbTest support his team to look beyond the information collected during clinical interviews and from rating scales.
How can the QbTest help support the schools understanding of a patient’s ADHD symptoms?
The QbTest report has been especially useful in supporting our work with schools, in particular with younger children. Before the pandemic, we would typically schedule school observations for patients, with permission from the parents, which would help us better understand the impact of a patient’s symptoms in the school environment.
Sometimes teachers don’t recognize symptoms of ADHD – more often the inattentiveness or the impulsivity goes unnoticed. The teachers might report back that the student jumps up from their desk, is disruptive or they’re not focused on what they’re supposed to be doing. When you show the teacher the report and what it shows it is like a flashbulb moment for them, where that students’ challenges suddenly make sense. It’s useful to be able to show the patient (and all those involved in supporting them) their symptoms in black and white on the report.
Teachers have found the report useful in terms of medication too. For some medications, they can wear off around two or three o’clock, and teachers become more attuned to when their student’s attention may start to fade. We can run a QbTest with patients at those times to see more clearly the impact of the medication wearing off. Understanding the impact of this can be important when considering how best to manage the class timetable and incorporate movement breaks and other suitable adjustments”
QbTest for observation
When you’re running a QbTest with a patient you also get a chance to observe their behavior, you might see that their foot is moving rapidly under the desk, their hands are moving or you see that, towards the end of the task, there’s a lot more movement – they’re getting more and more fidgety.
Such observations are useful; we can also get an idea of how the patient handles minor distractions, for example if there’s a knock-on a nearby door or the distant ring of the doorbell or something like that, this could explain a skew on the graph – it’s important for us to record these observations to add context to the QbTest report. By recording the time when these things occur in the task helps us identify the corresponding point on the graph; you can look at the report and say that’s when the doorbell rang for example.
Titration using patient feedback and objective data
We have found the QbTest a tremendous support. I think I’ve ran 270 QbTests so far and it can be used across the different phases of an ADHD assessment and treatment. When a patient is on medication, we try to adjust the dosage up and down to find the right titration – QbTest can help us to find out if the medication is having the optimal effect.
If the patient’s feedback is that their medication isn’t working, we use QbTest so we can get an objective view of a dip in concentration at a particular time of the day. If we don’t see the improvement that we would expect from QbTest, that’s when we look at the titration of the medication – increasing the dosage if they are still experiencing difficulties with their ADHD symptoms. We invite patients back for a follow-up appointment, to see if the adjustment to the medication made a difference, again using the QbTest.
Some patients will feel that there’s been an improvement and others won’t. Often the QbTest report helps the patient see, in most cases, the difference it has made. It helps them to reflect on some of the positive changes that have happened since they last did the QbTest – they feel more focused or more alert. The crucial thing is the time at which we intervene. When it comes to the time when they are taking their final exams at high school, they want to be focused and for their medication to be working properly. Often, that’s when we get the most engagement from patients in their own treatment, so they will volunteer to do another QbTest around exam time. This helps us to ensure that their dose of medication is helping them perform at their best academically. We want to make sure that everything is right, and they’re focused.
The report is also a useful form of encouragement for patients to see the progress they’ve made. We look back at their first QbTest and then look at the one completed in the last few days. We’ve had QbTest for two or three years now, so for some patients they have a comprehensive history of results and we’re astonished sometimes by the progress patients have made as we chart their progress over time”.
Managing transition – coming off medication
“When patients wish to stop their medication, usually around 17-18 years of age, we have a trial period without medication where we’ll use the QbTest to see the before effects with and without medication. That really helps the patient understand their symptoms better and make a more informed decision about whether to stop their medication or not.
As an overall package it works in that sense; from diagnosis to the end of treatment QbTest supports us along the way
Also, for older patients and those looking to stop treatment we’re giving them some autonomy in that decision thanks to the QbTest. It’s almost like we’re saying to them you’re an adult, it’s your decision – what do you think? Would you be happy to continue the way you are? If they go back to school and they’re still struggling to maintain concentration, they still have the option to go back on medication”.
Before and after QbTest
Before QbTest, we had to consult more with schools and patients. It was often a long, drawn out process, taking up to six weeks to collect all the information. Now we can get to inform schools of the diagnosis faster and get supports for the children set up faster ie movement breaks, one to one work, psychoeducation for teachers.
Now, with QbTest, we can collect all the evidence and data we need on the day of the clinical interview for ADHD with both the patient and the parents or guardians. Patients will undergo a QbTest as part of their clinical assessment. At the end of the assessment, we feedback to the parents/guardians, and to the child, the findings from the clinical interview, rating scales and QbTest. It’s great to be able to share the QbTest report with patients and parents/guardians and show on the chart in the report where their difficulties are, highlighting evidence of inattention, impulsivity or hyperactivity and discussing how it affects them.
If there is supporting evidence of an ADHD diagnosis, considering all the clinical measures, the patient can start treatment that day if necessary. In most cases, the QbTest reduces the number of appointments by 2-3 appointments in our care pathway. The net result is that it frees up more time to see more patients while continuing to provide quality care during the assessment process”.
Enhanced communication with patients
The QbTest report has been useful, especially with teens. Some patients are convinced that they are not hyperactive or impulsive. When I show them their performance on the QbTest compared to the norm group they can clearly see the difference. Sometimes the extent of their symptoms is clear cut, showing significant deviation from the norm group. For the patients it can be a learning curve and the first real, objective insight into their symptoms.
When patients who do receive an ADHD diagnosis come back after starting medication, we repeat the QbTest and we can assess whether the treatment is working effectively. You can see impact of the treatment by the changes in the output of the QbTest report and it further supports the patient to be an active participant, to see how their treatment is helping to improve their symptoms, which in many cases it is. Often, I find the report helps stimulate a conversation with the patients, with them giving feedback on whether they feel the treatment is working or that they notice the difference in school. The graph on the report is often a true reflection of what they feedback.
Using the data from QbTest for better understanding of symptoms for patients, parents/guardians and schools
We often have cases referred to us where one symptom is the primary concern. If, for example, we have a patient who comes to us with mostly inattentive symptoms which are affecting their performance at school, you can focus on the attention measures displayed on the report to understand their symptoms better. This can give us, the clinicians, the patients and the parents/guardians an objective glimpse of what is happening.
For some patients, when they’re in class, they may look like they’re paying attention, when in fact they’re not taking in any information. In these types of cases there is an extra effort on behalf of the school, to get that student the extra help, to show them where the difficulties are. So, QbTest is useful in being able to show schools and parents where best to focus their support, based on what is displayed on the report. If attention is the primary symptom, then schools can use that information to adapt the classroom for that student.
Enhancing psychoeducation for ADHD
There is no way I’d bring out a summary of a rating scale we use to discuss with patients, families or the school.
The QbTest is very handy. It’s one page and I think, once you can explain what you’re looking at on the sheet in front of you, it makes sense. The rating scales we use are subjective insofar as the answers can depend on the day or how the teacher or parent/guardian was feeling when it was filled in. Whereas QbTest is taken at a particular time and this is the way the child is. Objectively it’s direct feed back to the patient /parents there and then, not depending on others’ point of view.
The report itself is easy to understand with a dedicated patient report. The graphs on their own help us communicate with parents and the teachers. I am able to explain their ADHD symptoms in the context of their challenges at this particular time. The report shows you exactly what the difficulties are and when they occur during the task.