Attention Deficit Disorders and the Test of
Variables of Attention® (T.O.V.A. ™®)
Lawrence M. Greenberg, MD
Professor Emeritus of
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.
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
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:
- inattention and distractibility;
- hyperactivity and impulsivity ("disinhibition");
- 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
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
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
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
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
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
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
h) lack of school readiness, different learning style, and low
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
m) substance use, abuse, and withdrawal (including caffeine and
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
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
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
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
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
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
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.
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
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
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
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
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
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
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
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
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
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
How much does the T.O.V.A. ™ cost?
T.O.V.A. for Windows XP, Vista (all versions), Windows 7 (all versions), Windows 8 & 8.1 and Mac OS $895.00
Visual & Auditory T.O.V.A. ™ $895.00 - comes with 5 free interpretation credits
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