Can Computer Tests Help Diagnose ADHD in Young Offenders?

What you need to know

• ADHD is much more common in young offenders (up to 30%) compared to the general youth population (5%)
• This study tested the feasibility of using a computerized test called QbTest to help assess ADHD in youth detention facilities
• While the study showed QbTest could potentially be useful, there were significant challenges in implementing ADHD assessments in this environment

Background on ADHD in Young Offenders

Attention deficit hyperactivity disorder (ADHD) is a mental health condition characterized by problems with attention, hyperactivity, and impulsivity. While ADHD affects about 5% of children and teens in the general population, it is much more common among young people in juvenile detention and correctional facilities - with rates as high as 30%.

This high prevalence is concerning because untreated ADHD is associated with a range of negative outcomes, including poor academic performance, difficulties with social relationships, and an increased risk of criminal behavior. Early diagnosis and treatment of ADHD can help reduce these risks. However, assessing ADHD in young offenders presents unique challenges.

Challenges in Assessing ADHD in Detention Settings

Diagnosing ADHD typically involves gathering information from multiple sources, including parents, teachers, and the young person themselves. This can be difficult to do for youth in detention facilities, who may have limited contact with family members or teachers. Additionally, the assessment process often relies on subjective reports, which can lead to inconsistencies or delays in diagnosis.

Another issue is that many young people in detention facilities have complex needs and may be experiencing other mental health problems alongside ADHD. This can make it harder to tease apart symptoms and arrive at an accurate diagnosis.

Given these challenges, there is interest in using more objective measures to support ADHD assessment in juvenile justice settings. One such tool is the QbTest, a computerized test that measures attention, impulsivity, and physical activity.

What is the QbTest?

The QbTest combines two types of assessments:

1. A computerized continuous performance test (CPT) that measures attention and impulsivity
2. Motion tracking to measure physical activity during the test

The test takes about 20 minutes to complete. It provides objective data on core ADHD symptoms, which can be compared to age and gender norms. The QbTest is not meant to diagnose ADHD on its own, but rather to provide additional information to support clinical assessment.

Previous research in community settings has shown that using the QbTest alongside standard clinical assessment can help clinicians reach diagnostic decisions about ADHD more quickly and confidently. However, it was not known whether the QbTest would be feasible or helpful in juvenile detention settings.

The Current Study

Researchers conducted a feasibility study to explore whether a larger trial of the QbTest in juvenile detention facilities would be possible and worthwhile. The study took place in one Young Offenders Institution (YOI) in England, housing boys aged 15-18.

Study Design

The researchers recruited 60 young people who showed possible signs of ADHD based on an initial health screening. These participants were randomly assigned to one of two groups:

1. QbTest group: Received the QbTest in addition to usual ADHD assessment and care
2. Control group: Received only usual ADHD assessment and care

The study aimed to answer several questions:

• Is it feasible to recruit and retain participants for this type of study in a detention setting?
• Are young people and staff willing to engage with the QbTest?
• Can outcome measures be reliably collected?
• What are the potential barriers and facilitators to implementing the QbTest in this environment?

Key Findings

Feasibility of Recruitment and Study Procedures

• The study successfully recruited the target of 60 participants
• All participants agreed to be randomized and no one dropped out after being assigned to a group
• 78% of participants were followed up at 3 months, but only 32% at 6 months (partly due to COVID-19 restrictions)

These findings suggest that it is possible to recruit and retain participants for this type of study in a detention setting, at least in the short term. However, longer-term follow-up may be challenging due to the transient nature of the population and external factors like the pandemic.

Engagement with QbTest

• All 30 young people assigned to the QbTest group agreed to take the test
• 23% were unable to complete the test, mainly due to prison staffing issues or being released/transferred before the test could be done
• Feedback from young people was mixed - some found it helpful, while others found it long or boring

This indicates that while most young people are willing to engage with the QbTest, there are practical challenges in administering it within a detention facility. The mixed feedback also suggests a need to consider ways to make the test more engaging or to better explain its purpose to participants.

Collection of Outcome Measures

• Questionnaires completed by young people had good completion rates at 3 months (64-66%)
• Measures that relied on staff or teacher completion had very poor completion rates

This highlights the importance of focusing on outcomes that can be directly collected from the young people themselves in future studies.

Diagnostic Decisions

• Only 23% of participants received a decision on ADHD diagnosis during the study period
• All decisions made were exclusions of ADHD (no one received a positive diagnosis)

The low rate of diagnostic decisions is a significant finding. It suggests there may be broader issues with the ADHD assessment pathway in this setting that need to be addressed before a larger trial of the QbTest could be effective.

Staff Perspectives

Staff interviews revealed generally positive views about the QbTest:

• They felt it could be helpful in assessing ADHD and understanding young people’s behaviors
• Some believed it could improve waiting times and provide more objective information
• Staff thought the QbTest could be particularly useful for assessing complex cases

However, staff also identified challenges in implementing the QbTest, including finding appropriate quiet spaces to conduct the test and coordinating with prison staff to bring young people to appointments.

Implications and Future Directions

This feasibility study provides valuable insights into the potential use of the QbTest in juvenile detention settings. While there is promise in the approach, several issues need to be addressed before moving forward with a larger trial:

1. The ADHD assessment pathway in detention facilities needs improvement. The low rate of diagnostic decisions suggests systemic issues that go beyond the use of the QbTest.

2. Practical challenges in administering the QbTest need to be overcome. This might involve working with prison staff to establish dedicated times and spaces for testing.

3. Future studies should focus on outcomes that can be reliably collected from young people themselves, given the difficulties in obtaining information from staff and teachers.

4. Shorter follow-up periods (e.g., 3 months instead of 6) may be more feasible given the transient nature of the population.

5. There may be a need for more education and engagement with young people about the purpose and potential benefits of the QbTest to improve their experience.

Conclusions

• The study showed it is possible to conduct research on ADHD assessment tools in juvenile detention settings, but there are significant challenges to overcome
• The QbTest has potential to support ADHD assessment in this population, but its effectiveness is limited by broader issues in the assessment pathway
• Future research should focus on addressing systemic issues in ADHD assessment in detention facilities alongside testing specific tools like the QbTest
• Improving ADHD assessment and diagnosis in juvenile offenders remains an important goal, given the high prevalence of the condition and its impact on long-term outcomes

By addressing these challenges, researchers and clinicians can work towards better identification and support for young offenders with ADHD, potentially improving their chances of rehabilitation and positive life outcomes.