Practice advisory: The utility of EEG theta/beta power ratio in ADHD diagnosis

Abstract

Objective: To evaluate the evidence for EEG theta/beta power ratio for diagnosing, or helping to diagnose, attention-deficit/hyperactivity disorder (ADHD). Methods:We identified relevant studies and classified them using American Academy of Neurology criteria.Results: Two Class I studies assessing the ability of EEG theta/beta power ratio and EEG frontal beta power to identify patients with ADHD correctly identified 166 of 185 participants. Both studies evaluated theta/beta power ratio and frontal beta power in suspected ADHD or in syndromes typically included in an ADHD differential diagnosis. A bivariate model combining the diagnostic studies shows that the combination of EEG frontal beta power and theta/beta power ratio has relatively high sensitivity and specificity but is insufficiently accurate. Conclusions:It is unknown whether a combination of standard clinical examination and EEG theta/ beta power ratio increases diagnostic certainty of ADHD compared with clinical examination alone.Recommendations: Level B: Clinicians should inform patients with suspected ADHD and their families that the combination of EEG theta/beta power ratio and frontal beta power should not replace a standard clinical evaluation. There is a risk for significant harm to patients from ADHD misdiagnosis because of the unacceptably high false-positive diagnostic rate of EEG theta/beta power ratio and frontal beta power. Level R: Clinicians should inform patients with suspected ADHD and their families that the EEG theta/beta power ratio should not be used to confirm an ADHD diagnosis or to support further testing after a clinical evaluation, unless such diagnostic assessments occur in a research setting. In 2013, the US Food and Drug Administration (FDA) approved the Neuropsychiatric EEG-Based ADHD Assessment Aid (NEBA), stating that the NEBA "uses the theta/beta ratio of the EEG measured at electrode CZ on a patient 6-17 years of age combined with a clinician's evaluation to aid in the diagnosis of ADHD" and "should only be used by a clinician as confirmatory support for a completed clinical evaluation or as support for the clinician's decision to pursue further testing following a clinical evaluation."1 The FDA further stated that "(t)he device is NOT to be used as a stand-alone in the evaluation or diagnosis of ADHD." The NEBA calculates the ratio of the power of the EEG theta and beta bands at Cz, which is the EEG electrode halfway between the inion and the nasion.Individuals with attention-deficit/hyperactivity disorder (ADHD) demonstrate a persistent pattern of inattention or hyperactivity/impulsivity, or both, that interferes with functioning and is inappropriate for developmental age. ADHD is typically diagnosed with a clinical examination. Appendix e-1 at Neurology.org presents the DSM-5 clinical criteria used for ADHD diagnosis.2 The American Academy of Pediatrics clinical practice guideline for the diagnosis, evaluation, and treatment of ADHD in children and adolescents provides a strong recommendation that when asses...

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