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About Attention

Attention Deficit Disorders and the Test of Variables of Attention® (T.O.V.A. ™®)

Lawrence M. Greenberg, MD
Professor Emeritus of Psychiatry
University of Minnesota
Author of the T.O.V.A. ™

Please note that the following information contains the expressed opinions and conclusions of the author and is not intended as, nor may it be used as, medical advice. This information should not replace the clinical decisions of a licensed professional based on personal examination. The author shall have no responsibility for the use or misuse of this information.

Summary

The T.O.V.A. ™ provides objective and reliable measures of attention and impulsivity that the clinician can use along with history, interviews, behavior ratings and symptom checklists to accurately diagnose and treat attention disorders.

ADD and ADHD

Attention deficit disorders (ADD) is a descriptive term used by professionals to indicate that a child or an adult has a significant problem maintaining attention (that is, staying on task) when it is reasonable to expect them to be able to do so. There are many causes of inattention, ranging from boredom to neurological (including ADHD) and psychological problems. (See 3 below).

Attention Deficit Hyperactivity Disorder (ADHD) is the diagnosis currently used by clinicians to indicate a neurological disorder with three prominent clusters or groupings of problems that can occur separately or together:

  1. inattention and distractibility;
  2. hyperactivity and impulsivity ("disinhibition");
  3. disorganization or problems of "executive functioning"

In this review, I use the descriptive term, ADD, to refer to the presence of one or more of these symptoms, regardless of diagnosis. When I use the diagnostic term, ADHD, I am referring to the neurological disorder as described in the Diagnostic and Statistical Manual (DSM IV) that is currently used by clinicians. The symptoms of ADHD are grouped into four diagnostic categories based on the manifested symptoms: Inattentive Type, Hyperactive Type, Mixed Type, and Other.

Note: The diagnostic terms and the descriptive symptoms change with each new DSM as we learn more about the disorder. As an example, ADHD was previously called the Hyperkinetic Reaction of Childhood before we knew that only half of the children with ADHD are hyperactive, and that 4% of adults have ADHD.

In this review, I focus on the specific symptoms of ADHD (and ADD) that we "target" for treatment:

Inattention and distractibility

In ADHD, the brain often processes information too slowly and too quickly (that is, inconsistently) compared to persons who don't have ADHD. Persons with ADHD have difficulty staying on task and tend to be easily distracted and disorganized. Of course, they can and do compensate somewhat. However, as they get older, the information to be processed gets more complicated, there's a sequence of things to do rather just a few things at a time. Some children do fine until "show and tell" is replaced by primarily verbal or written instructions or material, especially in the mid-grade school years. Others do all right, even if they do work longer and harder than their peers, until high school, or, in some cases, until college when they just can't keep up with the others.

Even if the person is "hyperactive" and impulsive (see below) as well as inattentive, the brain processes information inconsistently. It's counterintuitive. We'd expect that a hyperactive person processes information too fast to keep things straight. However, the person with ADHD sometimes processes too slowly and responds with confusion, frustration, and a sense of failure because they can't understand the message or respond appropriately.

Half of the children with ADHD simply process information too slowly and/or are inconsistent, but they aren't hyperactive. Adults with ADHD aren't usually hyperactive even if they were as children- they "outgrow" the hyperactivity component although they often remain physically and/or verbally impulsive. Since children are usually referred to a clinician because they are disruptive and/or disrupted, children who are inattentive but not hyperactive are usually not referred and, instead, are thought to be uninterested, noncompliant, easily bored, or maybe even not too smart. These children often don't get to a clinician, and don't get diagnosed. Instead, they often end up with low self-esteem, being oppositional or self-rightious, and/or favor activities that hold their attention.

Case illustration: A medical student asked for a clinical consultation after hearing a lecture on adult ADHD. He'd been diagnosed as a child as having dyslexia (a reading problem) and received special educational services. He did all right in school but had to study much more that his peers, especially in high school and college. Since reading was a problem, reading assignments and tests were particularly difficult for him. He devised all sorts of coping strategies like taking frequent short breaks, and studying at night when it was quiet. He assumed that he was of average ability and attributed his academic progress to working so hard. The clinical assessment revealed that he had the inattentive type of ADHD. There was no evidence of dyslexia (although he may very well have had it as a youngster), and he was actually much smarter than he thought. He responded very well to medication (see 13, below), and is now a successful physician.

Hyperactivity and impulsivity

Persons with ADHD who are hyperactive (that is, overactive) and/or impulsive do not successfully control their behavior (leading to impulsivity and related problems) and/or do not modulate activity level (leading to hyperactivity). It’s like their "brakes" don’t work well- they have difficulty stopping and thinking before they act. They might be physically and/or verbally overactive.

As noted above, these are the children who are referred to a clinician because their behavior bothers others- they can be irritable, aggressive, destructive, and just downright obnoxious. Some are just all over the place- they can't sit or stand still for very long. And some are all of the above.

Case illustration: His parents have always had difficulty managing Bob's behavior. As an infant and a baby, he was difficult to settle down with frequently interrupted sleep, colic, and irritability. As a toddler, he was into everything- running into the street, breaking things, and still very irritable. Within days of starting preschool, after his teachers recommended that he be evaluated, it was determined that he had the mixed type of ADHD (both inattentive/distractible and hyperactive/impulsive). He responded nicely to medication (see 13, below), short term individual counseling, and parental consultations to help them manage his behavior more effectively and consistently.

We now know that over half of the children with either type of ADHD grow up to be adults with ADHD. If the diagnosis of ADHD (with or without hyperactivity) was missed in childhood, and the person did not "outgrow" the processing problem in the teen years, they can end up with complications of untreated ADHD, including low self-esteem/depression, obsessive-compulsive traits, excessive anxiety ("fear of failure"), antisocial traits, and/or substance abuse, using cocaine, alcohol, methamphetamine, marijuana, and excessive sleep medications. Individuals with untreated ADHD also tend to unconsciously self medicate with excessive amounts of caffeine and nicotine. (Both caffeine and nicotine are psychostimulants. They stimulate the brain. However, they are also very addicting and have some very nasty side effects.)

Disorganization (problems of "executive functioning")

Persons with ADHD often have difficulty "putting it all together". Sequential information is somehow all mixed up or lost when recorded in short term memory. When the person tries to retrieve the information from short term memory, some of the data are missing and some of the data don't make sense, making it difficult to respond appropriately and correctly assess the results. The person has difficulty organizing themselves- projects are begun and abandoned unfinished. Sometimes their sentences make sense, but their paragraphs don't, literally and figuratively.

It helps to be intelligent, and to be able to cope better than others, but people with executive functioning problems can't perform up to their ability even when working much harder than others. Frustrated, they try harder and/or give up.

Case illustration: A very successful scientist with a Ph.D. was promoted from a research position to manager of his section. Within days, he was overwhelmed by details and unable to keep organized. He'd always been a hard worker- even in school he studied far more than his peers and obtained good grades. A clinical evaluation revealed a very high IQ and inattentive type of ADHD with prominent executive functioning problems. Fortunately, he responded very well to coaching (focused on acquiring organizational skills and reducing distractions) and to medication (see 12 and 13, below).

The Cause(s) of Attention Disorders

Let's back up a moment. ADHD is really a misnomer. It's not really a disorder. By definition, a disorder has certain characteristic symptoms (signs and behaviors that are "abnormal"), a predictable natural history (what happens over time without treatment), and a common underlying cause ("etiology"). Treatment, if any, is directed to modify the symptoms or alter the underlying cause of the disorder.

Well, ADHD is a symptom complex, and the diagnosis is based on the presence of a sufficient number and severity of the symptoms that are listed in the current diagnostic handbook (DSM IV) that clinicians use. However, this exact complex of symptoms has many very different causes (etiologies) that have different natural histories, and respond to very different treatments.

There are many possible causes of an attention disorder, including:

a) it's normal, age appropriate behavior that is mislabeled; most of the overly active, difficult-to-manage children don't have ADHD;

Case illustration: Sue was a very intelligent, active, intrusive, and somewhat "bossy" six years old girl who was a "management" problem at home and in school. She always wanted to do it herself and didn’t "listen well". Her parents tended to be inconsistent in their behavior management attempts and to be easily irritated by her. Her teacher was boringly repetitive and pedantic. Sue didn’t have ADHD- she was what Linda Budd called "active alert". Perfectly normal. Things improved considerably with some behavior management counseling for the parents and consultation with the teacher.

Note: Linda Budd’s books on the active alert child are very, very helpful even if the child does have ADHD.

b) any number of general medical problems (such as anemia, hyperthyroidism, chronic ear infections, and dietary inclusions/sensitivities;

Clinical comment: Dietary sensitivities do exist although they are not very common. One of our studies done some years ago revealed that only one of twenty children whose ADHD symptoms reportedly "responded" to dietary management did, indeed, respond sufficiently to changes of diet.

c) many medications (such as anticonvulsants, antihistamines, and psychodepressants that sedate or slow the brain);

Comment: Since these medications are often necessary for the general well being of the person, it’s important to use the lowest effective dose to minimize side effects.

d) toxic conditions (drug induced or an illness);

e) sensory deficits (like undetected hearing and visual impairments) and sensory hypersensitivities;

Comment: The clinician needs to consider all of these potential problems when evaluating attention.

f) neurological problems other than ADHD, such as visual and/or auditory distractibility, sleep disturbances (including narcolepsy), epilepsy, "acquired/traumatic" or Traumatic Brain Injury (TBI);

Case illustration: A successful professional was seriously injured in an auto accident in which close relatives were killed. He was evaluated by teams of professionals, and, although he'd had a severe concussion, there was no sign of brain damage or memory impairment. His recovery was slow but steady with many surgeries, medications, and rehabilitation interventions. Several years later, he was telling a friend, a psychologist, that in spite of grief counseling, he remained "depressed"- he felt preoccupied and was distractible, frequently off task, disorganized, and easily bored. These are symptoms of depression, and they are also symptoms of ADHD, inattentive type. When his friend referred him for an ADHD assessment, it was discovered that the evaluation obtained after the accident did not include a T.O.V.A. ™ even though brain injuries can cause ADHD. It turned out that he did have traumatic ADHD, and his symptoms responded to treatment.

g) family style and (dis)organization (including social and cultural factors);

h) lack of school readiness, different learning style, and low motivation;

Comment: Some individuals learn best with a "hands on" experience rather than hearing or reading about it.

i) stress (including emotional trauma and inappropriate demands);

j) intellectual impairment and precocity;

k) learning disabilities;

l) other psychiatric conditions including abuse/post traumatic stress disorder, psychosis, bipolar or obsessive-compulsive disorders, autism, Tourette, depression, and anxiety;

Comment: A multi-faceted clinical evaluation is needed to determine whether one or more of these conditions exist with or without ADHD.

m) substance use, abuse, and withdrawal (including caffeine and nicotine);

Comment: Substance use and abuse are common in untreated individuals with ADHD, and the co-existence of ADHD makes the treatment of substance abuse more difficult. Although it seems counterintuitive to treat a substrance abuser with ADHD with low doses of psychostimulants (See 13 below), it’s the most effective treatment.

n) behavior disorder and oppositional/defiant;

Case illustration: Jack was six years old when seen by his family physician because of hyperactivity, impulsivity, stealing, and temper tantrums at home and at school where he was not progressing academically. Assuming that Jack had ADHD, combined type, the doctor prescribed 10 mg of methylphenidate (a psychostimulant). Jack initially appeared to be less hyperactive and impulsive. The dosage was increased to 20 mg with minimal improvement and some increase in irritability and sleep disturbance. Jack was subsequently seen for a psychological evaluation and was diagnosed and successfully treated for a behavior (conduct) disorder without medication.

o) and, finally, the neurological disorder of attention or ADHD

To complicate matters even further- these causes are not mutually exclusive. An individual with the ADHD symptom complex could very well have more that one cause co-existing ("co-morbidity") and needing more than one treatment modality. Prime examples would low self-esteem and depression. In addition, there can be a genetic component as well since a percentage of individuals with ADHD have close relatives with it also.

Sometimes "co-morbid" problems, like low self-esteem, are so prominent that the clinician may not recognize the underlying attention disorder. This is often the case in children with the Inattentive Type of ADHD and in adults whose ADHD wasn't diagnosed in childhood.

So, it's very important that the clinician carefully considers all of the possible causes of the symptom complex without leaping to a conclusion and prescribing a treatment. Selecting a diagnostician is not an easy task- you want someone who has the necessary expertise. An excellent source of information is The TOVA Company that maintains an up to date directory of clinicians who specialize in the diagnosis and treatment of attention disorders, including ADHD.

The Incidence (Frequency of Occurrence) of ADHD

The symptom complex of ADHD occurs in 6-7% of children and 5% of adults. The number of ADHD diagnoses is definitely increasing, in part reflecting the increased awareness by the general public and professionals alike. Some of the increase is due to assuming that every overly active youngster has ADHD. (See 3 above.) Some of the increase reflects the increasing number of brain injuries from accidents, etc.

While we used to think that there were many more males than females with ADHD, we now know that females tend to have the inattentive type of ADHD and are often missed because they're not bothering any one. The same was true for adults- we used to think that all of the children with ADHD "outgrew" it by the mid-teen years. Now we know that only half of them do although the hyperactivity component generally does drop out.

Diagnosing ADHD is not an easy process. Perhaps half of the children referred to us with the diagnosis of ADHD (and sometimes being treated as having ADHD) don't have ADHD. They have the symptom complex but not ADHD. On the other hand, there are at least as many undiagnosed children and adults who have ADHD (especially the inattentive type).

The Diagnosis of ADHD

The diagnosis of ADHD is made by a clinician who uses all of the pertinent and available information. The diagnosis is not made by a behavior rating or by a test (not even the T.O.V.A. ™) although they provide useful and necessary information.

The basic recommended steps to make a diagnosis of ADHD include:

a) a comprehensive medical, social, and psychological history,

b) an interview of the individual, in part to assess self-esteem and coping strategies,

c) behavior ratings from the classroom teacher and parents if a child or teenager or a self rating if an adult,

Note: Behavior ratings can be very helpful, but many of them are poorly designed, emphasizing the disruptive behaviors and not reliably measuring inattention or executive functions. Some of our favorite instruments are the SBCL, the ACTeRS, the BASC® for children and the BAADS for adults.

d) a symptom behavior check list (based on DSM IV) to accurately determine the presence and severity of symptoms,

e) review of any previous medical, psychological and educational assessments to determine whether there are additional problems that need to be taken into account,

f) the visual T.O.V.A. ™ and auditory T.O.V.A. ™-A to accurately measure attention, impulsivity, and related behaviors, and

g) consideration of referrals for additional psychological and educational assessments as well as neurological and medical consultations.

Obviously, the diagnosis and treatment of ADHD are not made on the basis of a five minute interview or in response to a reported comment by the teacher or employer. (See 13, below.)

With the current DSM IV, a clinician can categorize ADHD in four ways: Predominantly Inattentive Type, Predominantly Hyperactive-Impulsive Type, Combined Type, and Not Otherwise Specified. This discussion will focus on the targeted symptoms rather than the diagnostic classifications.

The T.O.V.A. ™ and T.O.V.A. ™-A.

The T.O.V.A. ™ is a computerized continuous performance test (CPT) that is used by clinicians and other professionals in the assessment and treatment of attention problems such as attention deficit disorders and traumatic brain injuries.

There are two T.O.V.A. ™ tests- the T.O.V.A. ™ measures visual information processing, and the T.O.V.A. ™-A. measures auditory information processing. Designed like computer games, both T.O.V.A. ™ tests are easy to administer to children (age four and older) as well as adults.

The visual T.O.V.A. ™ uses two simple geometric figures to measure attention, and the auditory T.O.V.A. ™-A. uses two tones. Unlike other CPTs, the T.O.V.A. ™ avoids the confounding effects of language, cultural differences, learning problems, memory, and processing complex sequences. The visual T.O.V.A. ™ target is a square with a second but smaller square inside of it, near the upper border. The nontarget is a square with the smaller square near the lower border. The auditory T.O.V.A. ™-A. uses two easily discriminated notes. The high note is the target, and the low note is the nontarget. That’s it- no complicated sequences of numbers or letters, no confusing colors or sounds. A target or a nontarget randomly flashes on the screen or is sounded every two seconds for a tenth of a second (100 msecs). The instructions are to press a specially designed, accurate microswitch as fast as you can every time a target appears or is heard, but not to press the microswitch when a nontarget appears or is heard. It’s important to be fast but not too fast- it’s just as important to avoid pressing the microswitch when it's a nontarget. It’s that simple.

Well, it actually isn’t that simple. The targets and nontargets are presented in two different patterns. In the first half of the test, the target randomly occurs once for every 3.5 nontargets. So the first half of the test is called the infrequent (target) condition. With the visual T.O.V.A. ™ you really have to focus on the screen, or you’ll miss the occasional target. With the auditory T.O.V.A. ™-A. you have to listen carefully, or you'll miss the occasional high note. The excitement (if there is any) wears off very quickly for the first half of the test is 10.8 minutes long. It gets very boring very soon, and that’s what we want- a measure of attention in a boring task.

The second half of the test is also 10.8 minutes long, and now the target occurs 3.5 times to every one random nontarget. So it’s called the frequent (target or response) condition. In contrast to the first half, you’re pressing the microswitch most of the time, and every once in a while you have to inhibit the natural tendency to respond because a random nontarget occurs. This half is more exciting than the first half and provides a measure of attention in a stimulating task.

Why do we need visual and auditory versions of the T.O.V.A. ™? Most people are "concordant" for both visual and auditory information processing. That is, they visually and aurally process information similarly whether it be slowly, quickly or in between. However, a significant number (estimated at 12%) of individuals are "discordant" and process visual and auditory information differently. That is, they may be significantly slower in one than in the other modality. So we need to test both visual and auditory processing.

The T.O.V.A. ™ and the T.O.V.A. ™-A. are used by many different professionals, including physicians (especially family practioners, neurologists, pediatricians and psychiatrists), nurse practitioners, psychologists, educational specialists, mental health counselors, social workers, hearing and speech specialists, and, of course, researchers.

Variables Measured by the T.O.V.A. ™

a) The consistency of the response times is called Response Time Variability and is measured in milliseconds. Response Time Variability is the most important measure of the T.O.V.A. ™ and tells us how consistent (or inconsistent) a person's Response Time is. People with ADHD are more inconsistent than others. That is, sometimes they respond to the target very slowly and sometimes very quickly. When "they're with it" they do well, but they're frequently "not with it".

b) The time it takes to respond to a target is called Response Time and is measured in milliseconds. This measure tells how fast (or slow) a person processes information and responds by pressing the microswitch. People with ADHD process slower than others.

c) d' (d prime) is derived from Signal Detection Theory and measures how quickly one’s performance worsens ( deteriorates ) over the 21.6 minutes of testing. People with ADHD "lose it" much more quickly than others.

d) When someone responds to the nontarget, it is called an Error of Commission and is a measure of impulsivity (also called disinhibition ). People with ADHD make many more Commission Errors than others.

e) When someone does not respond to the target, it is called an Error of Omission and is a measure of inattention. People with ADHD have more Omission Errors than others (without ADHD).

f) Post-Commission Response Times measure how much faster or slower a person becomes after mistakenly responding to a nontarget. People with ADHD usually slow down after a Commission Error as do others. This measure helps us to identify one of the other causes (like conduct disorder) of the symptom complex.

g) Multiple Responses are the number of times a person presses the microswitch more than once a target. Like others, people with ADHD usually press the microswitch only once per target. This measure helps us to identify other neurological conditions.

h) Anticipatory Responses measure how often a person presses the microswitch so quickly (<150 msec) that they’re probably guessing rather then waiting longer and being sure. People with ADHD tend to have high numbers of Anticipatory Responses.

Note: We are constantly revising the T.O.V.A. ™ as we learn more about ADHD. For example, people (kids especially) are training themselves to respond faster by playing computer games. To compensate for this increased speed, we shortened the Anticipatory Response time from 200 to 150 milliseconds.

i) The ADHD Score is a comparison of the person’s T.O.V.A. ™ performance to an age/gender specific group with ADHD. All of the other measures tell us how different this person's performance is when compared to others who do not have ADHD. The ADHD Score tells us how similar this person's performance is to others with ADHD.

The T.O.V.A. ™ Microswitch

In contrast to other commercially available CPTs that use the computer keyboard or mouse to record responses, the T.O.V.A. ™ uses a microswitch. Since Response Time Variability and Response Time are two very important measures (that is, two measures with the high correlations with the diagnosis of ADHD), we need to measure time very accurately to determine how fast and inconsistent Response Times are.

Why a microswitch? To obtain very accurate time measurements (i.e., ±1 msec). Computer keyboards and mouses, are not as reliable and can vary significantly (±28 msec). In addition, if you use a different computer with a different measurement error to retest someone, it's very difficult to compare the results.

"Norms"

Once testing is completed (21.6 minutes long for 6 years old and older and 10.8 minutes for 4 and 5 years old), the results are immediately analyzed, and the complete interpretation and graphics are available on the monitor and to be printed out.

The T.O.V.A. ™ Interpretation program compares the test results with the results of a large number of people who do not have an attention problem. The test results are interpreted and reported as within the normal expectable range or not. If within the normal range, the results are "not indicative of an attention disorder". If not within the normal range, the results are "deviant from the norm and compatible with an attention disorder".

As the brain matures and changes, it processes information faster and more accurately from childhood to the late teen years/early twenties, remains pretty steady until the early- to mid-sixties when it slows somewhat. (So it is accurate to say that younger adults are faster than older ones, but older ones can compensate by exercising better judgement.) It's also true that males and females process information differently.

Thus, age and gender make a difference. For instance, when comparing individuals without ADHD, eight year old boys perform differently than eight year old girls and differently than nine year old boys. And individuals with ADHD process more slowly and variably and with more errors than others in the corresponding age and gender group.

The T.O.V.A. ™ Interpretation program compares the performance of one individual with the "norms" (that is, the aggregate results of the same age and gender group of persons without ADHD). The larger (within reason) and more representative the "norm" group, the better. Unfortunately, in comparison with the T.O.V.A. ™, most CPTs have too small of a sample of individuals without ADHD per age and gender groupings.

Special T.O.V.A. ™ Features

The T.O.V.A. ™ is long enough, simple enough, boring enough, and so accurate that it's the best CPT. It's long enough to "catch" those individuals with ADHD who can "rise to the occasion" and do all right with shorter CPTs. It doesn't use complex, sequential targets that other CPTs do. It keeps the same boring presentation interval. And none of the other CPTs use a microswitch.

T.O.V.A. ™ Accuracy

Research has documented that T.O.V.A. ™ results correlate with the diagnosis of ADHD, Inattentive Type at least 84% of the time and with ADHD, Hyperactive-Impulsive Type at least 86% of the time. In the same study, the T.O.V.A. ™ correctly identified 89% of the non-ADHD children. Add in other relevant data from history, behavior ratings, etc., and the "hit rate"(the accuracy of the diagnosis) increases.

At the same time, the clinician needs to be aware of and take into consideration the many factors other than ADHD that could affect a person's T.O.V.A. ™ performance. As examples, if someone slept poorly the night before, the performance could be adversely affected. Conversely, if someone had two cups of coffee or a cola, their T.O.V.A. ™ performance might be enhanced. Again, the sophistication and knowledge of the clinician is very important in making a proper diagnosis and prescribing effective treatment.

Non-Medical Treatment of ADHD

Simply making the correct diagnosis and explaining it to the person with ADHD and the family can be very therapeutic. Especially with adults, it’s not uncommon at all to have the person cry during the interpretation session and feel relieved. Sometimes, just knowing that they aren’t "dumb" or "bad" is therapeutic. And not everyone with ADHD needs to be treated.

Focusing on "targeted" symptoms, there are many practical ways to treat ADHD. People who tend to get "overloaded" with too much happening at the same time, do better in an environment with less stimulation by reducing visual, auditory, and sometimes olfactory (smell) stimuli. That's why it might be best to take tests in a quiet room without other students, and to study with a clean desktop, facing a wall. For people who get bored easily, frequent, brief breaks can help along with a reduction of repetitious tasks. (Sometimes just standing for a few moments is sufficient.) Paradoxically, background music can be both calming (by masking extraneous sounds) and provide toward-task stimulation.

Of course, there are many helpful interventions that professionals can provide by helping increase self-esteem, improve study skills, improve parenting skills, and so on. These and many more practical and non-medical interventions (like behavior modification techniques and Biofeedback) are available. Certainly any related or additional problems (like a co-existing learning disability) need to be addressed as well as securing an optimal educational or work environment.

For more information about non-medical interventions, we suggest that you browse through the many ADHD books in your local book store or library or consult with one of the growing numbers of ADHD coaches.

Medical Treatment of ADHD

The most commonly prescribed medications to treat ADHD are the psychostimulants like the amphetamines (including dextroamphetamine, Dexedrine®, and Adderall®) and methylphenidate (including Ritalin® and Concerta®). There are a number of other medications (including antidepressants) and a bewildering number of short- and long-acting forms of psychostimulants, but let's leave those details to the prescribing professional.

A few words about selecting a nurse practitioner or physician might be helpful, especially if the person with ADHD is an adult since some physicians "don't believe" in adult ADHD. Many physicians simply don't know much about ADHD, and it's not simply a matter of their specialty. There are some family physicians who are very knowledgeable about ADHD and some pediatricians who know very little about ADHD. It's very important that the prescribing professional is keeping up on the current medical literature for ADHD- there's a lot of new, important information to be had. For instance, we used to prescribe psychostimulants on the basis of body weight (the larger the person, the higher the dose). We were prescribing way too much medication, resulting in too many side effects and non-compliance.

There's also a lot of misinformation about medication. As an example, advertisements in professional journals stressed that one relatively new medication lasted longer and eliminated the need for more than one administration a day. Well, it is advantageous to have longer acting medications, but the higher doses that were involved aren't as effective as lower doses, and side effects are more common. Another medication was introduced to the market with great fanfare as a replacement for psychostimulants. The publicity was phenomenal. Unfortunately, that particular medication appears to be effective only 50-60% of the time (compared to low doses of psychostimulants that are effective 90% of the time) and had some pretty serious side effects.

Now we know that small doses work quite well and have very few side effects. In general, low doses of psychostimulants enhance attention but may have little effect of impulsivity and hyperactivity. Higher doses of psychostimulants tend to reduce impulsivity and hyperactivity but have little effect on attention. Unfortunately, the two effects do not often overlap. Thus, we tend to treat attention problems with low doses of psychostimulants, and wait a suitable period of time to see whether impulsivity and hyperactivity get better as a result of improved attention. If not, a behavioral intervention or a second medication may be prescribed rather than increase the dose of the psychostimulant.

There are a number of advantages to using low doses of psychostimulants than other types of medications. They're the quickest and most effective medications for treating ADHD, and yet they are not addicting in low doses. Some physicians prefer to use antidepressants for adults with ADHD, but they aren't as effective as psychostimulants. The problem is that since a number of adults with ADHD are also substance users/abusers (including alcohol, caffeine, and nicotine as well as a variety of illicit drugs), many physicians are leery of treating a substance abuser with a frequently abused drug. However, the low doses of psychostimulants that we use with special precautions are not only effective, they're safe to use. And treating the underlying ADHD facilitates the successful treatment of substance abuse.

Measuring the Effectiveness of Medication

We can determine whether a given dose of medication will be effective by obtaining a medication challenge T.O.V.A. ™ Let's say that we decide that 5 mg of methylphenidate is a reasonable dose. We obtain a T.O.V.A. ™ (or T.O.V.A. ™-A.) 1.5 to 2 hours after the first dose of a short acting medication and 2.5 to 3 hours after the first dose of a long acting medication when the medication has reached peak effectiveness. If the T.O.V.A. ™ "normalizes" (that is, the performance is within normal limits) with medication, we've got it. If the T.O.V.A. ™ performance is better than baseline (the initial test without medication) but not within normal range, we obtain additional medication challenge T.O.V.A. ™ tests but with slightly higher doses until we get one that's within normal range. Interpreting medication challenge T.O.V.A. ™ tests does get a bit complicated since 5 mg of methylphenidate is too much for some teenagers and adults. So if the first on-medication T.O.V.A. ™ has some variables better than and some worse than the baseline test, we recommend lowering the dose (like to 2.5 mg) and retesting.

How can 2.5 mg of methylphenidate be enough medication- it's only half of a tablet? If someone had told me 15 years ago that I could successfully treat patients with ADHD with 2.5 mg or 1.25 (a quarter of a tablet), I'd have laughed at the suggestion. However, in recent years, using the T.O.V.A. ™, we have found that there are many patients with ADHD who respond quite well with such low doses and with fewer side effects. Although the literature (with higher doses) quotes 30-40% incidence of side effects, we encounter less than 3%. Unfortunately, if the prescriber is not using a test like the T.O.V.A. ™ to accurately measure the effects of medication on attention, the tendency is to over-prescribe and actually obtain less improvement and more side effects.

Once we have decided on the medication and the dose, we conduct a three to four week clinical trial of the medication and carefully monitor for side effects (see below) and determine effectiveness with an interim history, behavior ratings, and symptom check lists, and an on-medication T.O.V.A. ™ If there are no side effects, and the person is doing better on medication, we see them monthly for prescriptions and brief checkups and every six months for more in-depth checkups with an interview, behavior ratings, symptom check lists, new baseline (no medication) and on-medication T.O.V.A. ™ tests to determine whether the dose remains the same or needs to be changed.

One advantage of the psychostimulants is that they work very quickly- even with the first dose. We've had patients call the first afternoon to comment that now they knew what it was supposed to be like all those years.

In general, young children initially need little medication. The dose gradually increases until the early teen years when, contrary to what you might expect, it begins to decrease. The dose stabilizes by the early 20s until the 60s when it decreases even more.

Some individuals with ADHD seem to respond and do not need long term treatment. Perhaps they learn effective coping skills, and/or "they outgrow" the ADHD, and/or they make sufficient changes in their lives so that the symptoms aren't so problematic. However, others remain symptomatic and need lifelong treatment. That's why periodic assessments are necessary.

The earlier treatment is obtained, the better for many reasons. The brain changes (matures) considerably in childhood and the teen years. It continues to change in the adult years, but not as much. There's growing evidence that when children are treated and their information processing skills are enhanced, the brain can accommodate and "normalize".

In addition, early treatment prevents the development of secondary (to the ADHD) problems that can become even more troublesome than the ADHD. As an example, some children "sense" that something is wrong with them. They get in more trouble, or they don't learn as well as others, etc. But they don't know what's wrong. Girls and boys with the inattentive type of ADHD frequently develop negative self-opinions like "I'm dumb", "I'm a loser", or "I'm bad", and, developing low self-esteem, they "give up" too easily. Others, boys more that girls with ADHD, develop what appears to be an "I don't care" attitude and their hyperactivity and impulsivity escalate. Both responses result in low self-esteem. Low self-esteem often becomes a very difficult problem to treat once it gets "wired in", and often leads to other difficult-to-treat problems like substance use/abuse, academic and vocational failures, and depression.

Side Effects of Psychostimulants

Although the incidence of "side effects" (unwanted effects) is remarkably low with small doses of psychostimulants, they occur frequently when the dose is too high and often may be handled by simply decreasing the dose, assuming that the lower dose is effective.

The side effects are somewhat different for children than for teenagers and adults. Children can experience irritability, crying, headaches, loss of appetite, stomach aches, and "rebound" (increased irritability and hyperactivity as the medicine is wearing off). Their ADHD symptoms might get worse, especially with too much medication. Some children sleep better, and others have difficulty falling and staying asleep. Weight loss can occur and usually responds to giving the medication with rather than before a meal. Although it was reported that children on psychostimulants may have short stature, that's a rare and transitory problem. Facial grimacing and tics (involuntary jerky movements of the head, trunk, and/or of the arms and legs) can appear or can worsen (if they were there before medication was begun). Adults most frequently experience feeling jittery or nervous when the dose is too high. When side effects occur, they should promptly be checked out by the nurse practitioner or physician.

Psychostimulants and Addiction

The question most frequently asked is whether the psychostimulants are addicting and habituating (that is, the person will gradually need more and more medication to respond to it). The answer: No. You'd have to quadruple (or more) the usual dose and take it not the usual once or twice a day, but four or more times a day (and night). Taken as prescribed, psychostimulants are less addicting that alcohol, caffeine, and nicotine. And to remain effective, the dose does not to be gradually increased.

Interestingly, research has documented that adults who were treated successfully as children with a psychostimulant used less substances (including caffeine and nicotine) than adults who weren't treated for their ADHD in childhood and than adults who didn't have ADHD. In addition, substance abusers with ADHD respond better to treatment when their ADHD is also treated.

For more details, see the T.O.V.A. ™ Clinical Guide. The TOVA Company has full time technical and clinical staffs that are solely dedicated to support of the T.O.V.A. ™ The T.O.V.A. ™ Research Foundation supports and provides technical assistance for research in attention and related areas.

 

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