To summarize, the study’s comparison is between the following two diagnostic methods for ADHD:
1. Best estimate diagnosis: A multidisciplinary team that never saw the patient and is basing the diagnosis on retrospectively reading chart notes and psychological testing results.
2. The NEBA interpretation: The EEG theta/beta ratio, combined in some way with the clinician’s diagnosis.
The Study Results
Here are the basic results for the NEBA as compared to their gold standard diagnosis, separated out by age group.
1. Adolescents (12-18):
a. Sensitivity: 89% (Sensitivity= the proportion of people with the disease who test positive)
b. Specificity: 79% (Specificity= the proportion of patients without the disease who test negative)
c. Positive predictive value: 81% (PPV= the proportion of patients with a positive test who actually have the disease)
d. Negative predictive value: 93% (NPV= the proportion of patients with negative tests who do not have the disease)
2. Children (6-12):
a. Sensitivity: 79%
b. Specificity: 97%
c. PPV: 96%
d. NPV: 82%
These numbers are pretty good. For example, a 96% PPV for children means that 96% of kids with a positive NEBA had ADHD. The PPV for adolescents is less impressive—81%, meaning that 19% of adolescents with a positive NEBA did not have ADHD. Nonetheless, these are all robust numbers—as long as the information that we get is actually clinically useful.
Is it Clinically Useful?
A positive NEBA provides “confirmatory support” that your patient has a cluster of symptoms that we commonly label “ADHD.” But wait—isn’t this what we already do? We ask a series of questions and we make observations in order to ascertain whether there is a particular cluster of symptoms labeled ADHD. What the NEBA does for us is it says, “Yes, I confirm that you recognized that your patient has an attention issue, labeled ADHD by DSM-5” How does this help me? I’m not sure. It’s telling me that an apple is, indeed, an apple.
Recognizing that there is an attention problem is the easy part—we often know this before the child even enters the room, and we definitely know after talking to the parents for 30 seconds. We don’t need an EEG to tell us this. And NEBA can’t provide information to help us with any of the following crucial questions:
• What comorbidities does the patient have that will affect our choice of treatment? A positive NEBA result may be specific for differentiating some problem from no problem, but it cannot distinguish ADHD from a host of conditions that often accompany the disorder—or can be mistaken for ADHD. At least two-thirds of kids with ADHD have a comorbid diagnosis, such as anxiety disorders, oppositional defiant disorder, learning disorders, or mood disorders (http://bit.ly/1Bla0EL).
• How severe are the symptoms? Are they mild enough so that the child can stay in the same school or so severe that a change might be needed?
• Should I start a stimulant?
• Should I refer to a behavioral therapist?
NEBA provides no information on any of the issues that affect treatment— which is just another way of saying that NEBA has little, if any, clinical utility. All NEBA can do is tell us that an attentional issue is an attentional issue. Full stop. How much is that worth to you—or, more relevantly, to your patients?
Lest it appear that we are trashing NEBA, we are not—we’re simply pointing out that it’s a promising technology with no proven clinical benefit. The next step for the company would be to demonstrate that benefit. A good way to do this would be to conduct a randomized trial—recruit 200 kids arriving at clinics for evaluations and then randomly assign 100 to standard evaluation and 100 to standard evaluation plus NEBA. Re-evaluate three to six months later, comparing the two groups. Here are some questions I’d be interested in:
• Does NEBA improve diagnostic certainty, as measured by a scale given to clinicians?
• Can it result in more rapid initiation of treatment?
• Does it lead to more rapid symptoms improvement?
• Will it improve parental satisfaction?
There are many other questions. These could be answered by appropriate research, and we hope to see such studies in the future.
CCPR’s VERDICT: Not ready for prime time. We recommend avoiding NEBA and instead focusing your energy on the less technologically exciting basics—figuring out the individualized treatment plans needed to help kids succeed despite their ADHD.