NEBA Test for ADHD: Historic but Problematic

On July 15, 2013 the FDA approved the marketing of the first device to be used in the diagnosis of ADHD.   The NEBA (Neuropsychiatric EEG-Based Assessment Aid) system is based on the observation that on average, people with ADHD have different brain waves than people who do not have ADHD.  Approval of the device is potentially  historic on several levels.

Before the approval of NEBA, no objective test has ever been approved for the diagnosis of ADHD.  For generations, ADHD has been diagnosed using a combination of a doctor's evaluation and parent and teacher rating questionnaires.  The accuracy of the diagnosis is highly subjective:   dependent on the evaluating doctor, the parents, and the teachers providing the information.  Traditional diagnosis based only on clinician evaluation and review of parent and teacher questionnaire has been shown to be somewhat unreliable as compared to expert evaluation.  The addition of the NEBA system to the diagnostic procedure may improve accuracy in the diagnosis of ADHD for primary care doctors and other clinicians who are not experts in pediatric ADHD.

If NEBA is really as good as it seems, then a few important consequences could be forseen.

1)  Diagnosis of ADHD will become more objective, legitimizing the diagnosis and freeing it from accusations that it is a behavioral problem only, caused by poor parenting, or by the might of the psychopharmaceutical industry.

2)  People who are looking for prescription medication for ADHD for other reasons, like addiction or drug dealing, will be easier to weed out, hopefully stemming the growing tide of overdoses and prescription drug addiction.

There are several problems, however, with NEBA, that make it less than ideal.

First, the numbers presented in the trial which convinced the FDA to allow the device to be marketed show elevated diagnostic accuracy when compared to other trials using EEG for diagnosis of ADHD in children.   The company making the NEBA system has not had verification of its numbers by researchers who are not also stockholders of their company.

Second, the brain wave changes noted on average in the ADHD population are just averages.  A large proportion of people--16% in one study--with ADHD by current diagnostic criteria do not have the brain wave changes detected by NEBA. A doctor certainly couldn't deny a prescription based on those numbers, but he or she might ask for more evaluation.

Third, while its reassuring that the NEBA provides an objective number, the fact is that it doesn't really add anything to a properly done expert evaluation.  The NEBA can only partially replace an expert evaluation, since in some studies, more than 60% of children presenting with symptoms of ADHD have more than one diagnosis, including autism, anxiety, depression, and oppositional defiant disorder.  NEBA cannot diagnoses any of those.  In the face of ballooning numbers of ADHD diagnoses, the country is in need of more experts, not necessarily more devices.

Reference:

Loo, Sandra K., and Scott Makeig. "Clinical Utility of EEG in Attention-deficit/hyperactivity Disorder: A Research Update." Neurotherapeutics 9.3 (2012): 569-87. Print.

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