Title: Optimising medication management in children and young people with Attention Deficit/Hyperactivity Disorder (ADHD) using an objective measure of attention, impulsivity and activity (QbTest): A feasibility study
Funder: Department of Health and Social Care

Abstract: Background: Attention Deficit/Hyperactivity Disorder (ADHD) is characterised by developmentally inappropriate and functionally impairing inattention, hyperactivity and impulsivity. The condition affects 3-5% of school-aged children and continues into adulthood in the majority of cases. NICE ADHD guidelines (2008) recommend regular monitoring of symptoms when children commence medication, particularly during initial dose titration, to improve immediate and long-term outcomes for the child. Our work (Hall et al., 2016a) indicates that regular symptom monitoring rarely happens in ADHD services due to insufficient resources. Moreover, clinicians rely on information gathered from parents and teachers to aid their judgement of whether symptoms have improved on medication. These sources are unreliable, subjective and difficult to obtain. A computerised, objective assessment of ADHD symptoms, the Quantified Behaviour Test (QbTest) combines a test of attention and impulse control (the Continuous Performance Test) with a motion tracker to measure hyperactivity. The test takes 15 minutes to complete and provides summary scores in each of 3 symptom domains (inattention, impulsivity, hyperactivity). Clinicians can review this information immediately, with the child and family, in order to decide whether the current dose of medication is effective, needs to be adjusted or replaced with an alternative medication. QbTest reduces reliance on subjective informant reports and provides a more immediate result that can aid rapid decision-making during dose adjustment. Although evidence supports the role of QbTest as an aid to clinical decision-making at the point of assessment and diagnosis (Hall et al., 2016b), and our own qualitative evidence (Hall et al. in prep), indicates that clinicians value QbTest as an aid to medication management, there is currently no standardised method for using this tool in clinical practice to aid medication management. Aims: In the long term we aim to conduct a randomised controlled trial to evaluate whether QbTest improves medication management for ADHD, leading to faster reduction in symptoms and better outcomes for children. As part of a process evaluation, we first aim to develop a QbTest medication management protocol that is acceptable to young people with ADHD, their families and clinicians and then test the feasibility of the future RCT design that will evaluate this protocol. The research questions of this study are: what is an appropriate QbTest protocol that is acceptable to clinicians and service users and secondly, what is the most appropriate study design for the future RCT? Plan of Investigation: First, we will conduct a series of expert workshops where we bring together a panel of parents of children with ADHD and clinical experts in ADHD (including some currently using QbTest) to develop a medication management protocol that involves using QbTest to assess medication response in children with ADHD. Next, we will conduct a feasibility RCT in which children at 3 different ADHD clinics in the UK will be randomised to receive treatment as usual or the QbTest medication management protocol. This feasibility study will enable us to gather information needed to design the future RCT. We will also examine the opinions of parents, children and healthcare professionals to measure the acceptability of the protocol and we will explore opinions of clinical commissioners and service managers to gain early insight into any barriers to implementing the protocol in clinical practice. If the findings indicate that the protocol is feasible and acceptable, this may lead to early adoption of the protocol into the clinics involved in the study, leading to better standardisation of approaches to using QbTest in medication management. The future trial will evaluate the benefits of the protocol to young people with ADHD, their families and the NHS, including an evaluation of health economics.

Lay abstract: Attention Deficit/Hyperactivity Disorder (ADHD) is a condition that affects 3-5% of young people under 18-years-old. Young people with ADHD have difficulties with attention, impulsivity and hyperactivity that make it harder for them to learn, form relationships and prepare for adulthood. Clinical guidelines state that young people taking medication for ADHD must be closely monitored and have their medication reviewed regularly to ensure they receive the correct dose to improve their symptoms. However, many young people aren t monitored closely enough. This can lead to lack of improvement or worsening of symptoms meaning that children may not benefit from medication as quickly as they should. At the moment, assessing whether or not medication is working relies on the opinions of teachers and parents, collected through questionnaires. The difficulties of this are: differences of opinion between people, lack of information provided by them, and not returning the questionnaires. A test performed on a computer (QbTest) provides doctors with a report of the young person s symptoms and can therefore show whether medication is working. This may help doctors reach accurate decisions about medication dose more quickly, reducing the need for questionnaires. In this study we will meet with families and young people with ADHD and medical experts to develop a procedure for using QbTest to measure medication effects. We will measure how well this works in the real world by asking a group of young people to complete the test when they first start taking medication and at their follow-up appointments. We will ask doctors and families/young people for their opinions on the procedure. We shall share our findings with other researchers and the public by attending local support groups and providing summaries of the study results. The findings will be used to prepare for a larger study to investigate QbTest in more clinics.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: MENTAL HEALTH