10. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
11. Miss A complains the Service wrongly decided she did not meet the criteria for ADHD due to the results of the questionnaires from home and school, the QbTest and school report.
12. NICE guidance explains a diagnosis of ADHD requires at least moderate psychological, social and/or educational or occupational impairment which is pervasive in two or more important settings including home, school or work.
13. The QbTest is relatively new technology. At the time of Miss A’s triage there was no formal guidance in place about that test.
14. The Service’s ADHD pathway explains a referral can come in from a GP or other professional to the community paediatrician where they are triaged. At this point the Service will request teacher reports and rating scales as well as a hearing, vision and developmental check if required. If there is no indication of ADHD the service will discharge the person back to the GP. If ADHD is suspected then the Service will carry out a full assessment, parent rating scale, DSM4 rating scale and a QB test for older children. At this point the child is either diagnosed with ADHD or is not.
15. After the Service received the referral for Miss A, it requested a school report, a Conners’ ADHD assessment questionnaire, and a questionnaire from Miss A’s parents.
16. When the Service received this information back it triaged it. It said at this point there was not an indication for ADHD but decided Miss A should do the QbTest for further information.
17. Our clinical adviser said information from Miss A’s school showed no indication of ADHD symptoms, and no evidence of impact on Miss A’s behaviour in school. They said the home questionnaire did show an indication of some inattention.
18. After the QbTest the Service re-triaged Miss A’s results. It decided she did not meet their referral criteria for ADHD assessment on the basis that the QbTest and school rating scale did not provide sufficient evidence of ADHD traits.
19. Our clinical adviser said the QbTest also did not show any strong indication of ADHD though it did show some inattention.
20. Our clinical adviser explained it is a clinical judgement by the paediatrician whether or not to put a child forward for an assessment. There is no guidance or standards which give specific scores where a child will automatically be given a full assessment. Our clinical adviser said there is no indication the Service made the wrong decision based on the evidence available to it.
21. Miss A’s father, Mr A, expressed concerns that Miss A became ‘hyperfocused’ in the QbTest and so the results were not reflective of her usual inattention. Hyperfocus is described as an intense fixation or focus on a specific task or thing. Mr A also believes she did score highly in this test and that should have indicated she needed a full assessment. He is concerned some of the questionnaire questions were not appropriate for teenage girls.
22. Mr A is also concerned the school questionnaire was completed by administrators at school who did not have experience with Miss A. He believes Miss A is good at ‘masking’ at school so signs of her inattention may be less obvious. Masking is a term used to describe when neurodiverse people feel the need to hide symptoms of their neurodiversity, such as inattention, to blend into social settings.
23. Our adviser said the QbTest results indicated Miss A can pay attention. They suggested it is common that in structured environments, such as school, children can find it easier to pay attention, but at home they can present differently. They said the Service sought appropriate information from the school. The school attached information from each of Miss A’s classes, suggesting it spoke directly to the teachers who are interacting with her directly. Our adviser said structured questionnaires do have positive and negative elements. This is why they are not used in isolation. Here it was part of an overall picture that led the Service to decide Miss A did not show indications of ADHD at that particular time.
24. There is no indication the Service did not follow its ADHD pathway with Miss A’s referral. The Service did not decide Miss A does not have ADHD but rather there was not enough evidence it affects her at school to meet its criteria for a full assessment. NICE guidance says that in order for an ADHD diagnosis to be eventually made, there needs to be evidence of at least moderate psychological, social or educational impairment which affects two or more settings, for instance home and school. In Miss A’s case there was no strong evidence of impact on her behaviour or attainment in school. Therefore, we see no indication the Service’s decision was not in line with NICE guidance.
25. We understand Miss A and her family were disappointed the Service did not give Miss A a full assessment. We hope our decision can provide some further explanation for Miss A and her family.