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Robert A' Leark, Ph'D'

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Attention & executive functioning ... Attention is not a unitary construct ... some have used from 50 to 1500 ms (Friedman, Vaughan & Erlenmeyer-Kimling (1981) ... – PowerPoint PPT presentation

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Title: Robert A' Leark, Ph'D'


1
Theoretical Models of Explanation
  • Robert A. Leark, Ph.D.
  • Fellow, National Academy of Neuropsychology
  • Associate Professor, Behavioral Social Sciences
  • Pacific Christian College, Fullerton, CA
  • Vice President, Research Development, UAD., Inc

2
Theoretical Models of Explanation
  • Multiple models of explanation for ADHD
  • Two have emerged as primary theories
  • Barkley Gordon
  • Brown
  • Attention executive functioning is
    multifaceted difficult to map

3
Theoretical Models of Explanation
  • Recent Historical Models
  • Attention is not a unitary construct
  • Zubin (1995) attention conceptualized as having
    multiple components or elements
  • Psychiatric modelsattention is process that
    controls the flow of information processing

4
Theoretical Models of Explanation
  • Recent Historical Models
  • Psychiatric models 3 components of attention
  • selectivity
  • capacity
  • sustained concentration
  • All of these must be sufficient enough to
    interfere with daily activities

5
Theoretical Models of Explanation
  • Recent Historical Models
  • Neuropsychologists typically conceptualize
    attention as
  • selective processing
  • awareness of stimuli

6
Theoretical Models of Explanation
  • Recent Historical Models
  • Neuropsychologists use attention to refer to
  • initiation or focusing of attention
  • sustaining attention or vigilance
  • inhibiting response to irrelevant stimuli
    (selective attention)
  • shifting of attention

7
Theoretical Models of Explanation
  • Riccio, Reynolds Lowe (2001) summarize
    components of attention
  • Arousal/alertness
  • motor intention/initiation
  • Selective Attention
  • focusing of attention (inhibiting/filtering)
  • divided attention
  • encoding, rehearsal retrieval
  • Sustaining attention/concentration
  • Shifting of attention

8
Theoretical Models of Explanation
  • Historical
  • Broadbent (1973) - capacity to take in
    information is limited, thus information not
    relevant needs to be filtered out. Information
    filtered out dependent upon stimulus
    characteristics (intensity, importance, novelty,
    etc.)

9
Theoretical Models of Explanation
  • Historical
  • 2nd model stresses arousal - here optimal arousal
    (alertness) is necessary for effortful, organized
    function (Hebb, 1958)
  • Pribram (1975) - arousal is short-lived response
    to stimulus. Arousal is the general state of the
    individual that allows for effects attentional
    processing

10
Theoretical Models of Explanation
  • Historical
  • Mirsky (1987) proposed three factor model for
    attention
  • focusing of attention
  • sustaining of attention
  • shifting of attention

11
Theoretical Models of Explanation
  • Historical
  • Mirsky model
  • selective attention part of process of focusing
    attention (level of distractibility if deficient)
  • Sustained attention ability to maintain that
    focus over time
  • Shifting of attention necessary for adaptation
    inhibition

12
Theoretical Models of Explanation
  • Historical
  • Lurias model
  • attention central to model
  • 2 attentional systems reflexive nonreflexive
  • reflexive orienting response/appears early in
    development
  • nonreflexive result of social learning/develops
    slower
  • limbic system frontal lobe mediate attention

13
Theoretical Models of Explanation
  • Historical
  • Lurias model
  • executive functions linked to mediating attention
  • executive functions
  • self-direction
  • goal directedness
  • self-regulation
  • response selection
  • response inhibition

14
Theoretical Models of Explanation
  • Mesulam (1981) model similar to Lurias
  • Model was specific to understanding phenomenon of
    hemiattention or hemineglect as result of brain
    damage
  • Attentional processes reticular system, limbic
    system, frontal cortex posterior parietal cortex

15
Theoretical Models of Explanation
  • Mesulam (1981)
  • Subcortical influences from limbic system, RAS
    hypothalamus part of system matrix needed for
    control of attention
  • Frontal lobes influenced by also influence the
    subcortical activity

16
Theoretical Models of Explanation
  • Historical
  • Summary attention involves at least two separate
    neural systems
  • activation system thought to be centered in left
    hemisphere involved in sequential/analytic
    operations
  • arousal thought to be centered in right
    hemisphere involved in parallel or holistic
    processing maintenance of attention

17
Theoretical Models of Explanation
  • Barkley Gordon (1994,1997,1998,2001)
  • inattention emerges alongside a general pattern
    of impulsiveness hyperactivity
  • deficits in self-control lead to secondary
    impairments in four executive functions

18
Theoretical Models of Explanation
  • Barkley Gordon (1994,1997,1998,2001)
  • Nonverbal working memory - sensing to the self
  • verbal working memory - internalized speech
  • emotional/motivation self regulation - private
    emotion/motivation to the self
  • reconstruction or generativity - cover play
    behavioral simulation to the self

19
Theoretical Models of Explanation
  • Barkley Gordon (1994,1997,1998,2001)
  • basal ganglia
  • dopaminergic
  • disinhibition key factor to etiology

20
Theoretical Models of Explanation
  • Barkley Gordon (2001)
  • ADHD is a longstanding, pervasive and chronically
    impairing consequence of poor inhibition and/or
    inattention
  • model is consistent with the DSM-Ivr criteria
  • symptoms occur prior to age 7

21
Theoretical Models of Explanation
  • Brown (1996)
  • etiology is on purely inattentive
  • stresses there has been an over-focus on
    disinhibition and an under appreciation of
    arousal, activation and working memory
  • onset of symptoms can occur after age 7

22
Theoretical Models of Explanation
  • Brown
  • ADHD criteria includes inattentive individuals
    who are not impulsive
  • all inattention is ADD/ADHD
  • ADHD is a suitable diagnosis for a broad range of
    symptoms
  • Browns rating scale BADDS - modeled upon this
    theoretical approach

23
Theoretical Models of Explanation
  • Brown - ADD/ADHD is still an executive
    dysfunction of five clusters
  • organizing activating to work
  • sustaining attention concentration
  • sustaining energy effort
  • managing affective interference
  • utilizing working memory recall

24
Theoretical Models of Explanation
  • Key components of models
  • inattention is the king of all nonspecific
    symptoms (Gordon, 1995)
  • inattention can emerge as a feature from a
    variety of psychiatric medical circumstances

25
Clinical Care
  • History - conception through current age
  • early life predictors
  • poor or inability to establish early life
    routines
  • motor hyperactivity at early age
  • ADHD is a diagnosis by exclusion
  • low APGAR
  • hypoxia
  • central nervous system diseases

26
Issues in Clinical Care
27
Clinical Care
  • History
  • ADHD is a diagnosis by exclusion
  • head injury/loss of consciousness
  • metabolic disorders
  • seizure disorders
  • apnea
  • other medical conditions
  • Other psychiatric conditions

28
Clinical Care
  • History
  • ADHD is a diagnosis by exclusion
  • ADHD is diagnosed only when other disorders do
    not best account for the symptoms
  • symptoms may be same, etiology somewhat different
    (or unknown)
  • treatment may even be the same

29
Clinical Care
  • History
  • Problems with overlapping co-morbidity create
    need to be able to stick to DSM IV criteria age
    7 issue
  • May not be possible to determine if signs
    symptoms might have been present (such as
    trauma-abuse cases) if such trauma had not occured

30
Clinical Care
  • Diagnostic procedures
  • Behavioral rating scales
  • Measure of sustained attention impulse control
  • Medication follow-up

31
Clinical Care
  • Behavior Rating Scales
  • Child-Behavior Checklist (CBCL)
  • Parent Rating
  • Teacher Rating
  • Item pure scales no item overlap

32
Clinical Care
  • Behavior Rating Scales
  • BASC (Reynolds Kamphaus)
  • Ages 2 - 18
  • Item pure scales no item overlap
  • easy to administer
  • shorter about 140 items

33
Clinical Care
  • Behavior Rating Scales
  • BASC (Reynolds Kamphaus)
  • 2-6 parent/other ratings
  • 7-12 self rating
  • parent rating
  • teacher rating
  • student observation guide

34
Clinical Care
  • Behavior Rating Scales
  • BASC (Reynolds Kamphaus)
  • 13-18 self
  • parent
  • teacher
  • student observation guide

35
Clinical Care
  • Behavior Rating Scales
  • BASC (Reynolds Kamphaus)
  • New ADHD predictor
  • derived from discriminant function analysis
    using best predictors

36
Clinical Care
  • Behavior Rating Scales
  • Parent Ratings generally show more impairment for
    child than do Teacher Ratings
  • May want to use blind ratings from Teacher -
    where Teacher is unaware of use of medication
  • helpful with treatment follow up studies

37
Clinical Care Issues
  • Treatment Issues
  • Treatment consistent with theoretical models for
    ADHD?
  • NIMH Treatment Guidelines
  • Medication effective, data indicated medication
    alone more effective than
  • Medication behavioral treatment
  • Behavioral treatment alone
  • Other modalities

38
Clinical Care Issues
  • Behavioral therapies
  • Treatment goal improve/increase inhibition
  • Treatment strategies must be consistent with goal
  • Treatment strategies must be incorporated into
    family system
  • Often source of increase problems if family not
    stable
  • Noncompliance by parents

39
Clinical Care Issues
  • Newer treatment modalities
  • Neurofeedback
  • Issuesstandardization of treatment
  • Length of treatment
  • Treatment cessation maintenance of gains

40
Clinical Care
  • Treatment considerations
  • Stimulant medication is standard of care
  • NIMH revenue of ADHD studies suggested that
  • Stimulant medication alone better than stimulant
    medication and behavioral therapy, behavioral
    therapy alone or placebo.

41
Clinical Care
  • Treatment considerations
  • Medications
  • methylphenidate hydrochloride
  • Ritalin
  • Sustained Release
  • Concerta
  • Amphetamines
  • Adderall
  • Dexedrine

42
Clinical Care
  • Treatment considerations
  • Medication Issues
  • kg/mg - is this an appropriate method for
    titration?
  • Titration to cognitive measures produces an
    overall lower mean dosage than for behavioral
    measures
  • b.i.d. or t.i.d.
  • Dosage?
  • Time of day?

43
Clinical Care
  • Treatment considerations
  • Behavioral Treatment
  • home and classroom based intervention strategies
  • requires cooperation of parents teachers
  • effective - but best when used with medication

44
Clinical Care
  • Treatment considerations
  • Family Therapies
  • Family system with behavioral interventions for
    child
  • Does require intact family system

45
Clinical Care
  • Treatment considerations
  • Stimulant medication is standard of care
  • NIMH revenue of ADHD studies suggested that
  • Stimulant medication alone better than stimulant
    medication and behavioral therapy, behavioral
    therapy alone or placebo.

46
Clinical Care Issues
  • Summary treatment goals and plans need to be
    consistent with theoretical models of ADHD
  • Medication ritalin, adderall, others

47
Clinical Care Issues
  • Summary treatment goals and plans need to be
    consistent with theoretical models of ADHD
  • Medication ritalin, adderall, others

48
Continuous performance tests
49
  • Grew out of need to provide for a measurement of
    attention and impulse control
  • Wanted actual measurement not behavioral
    attributes

50
  • Advances in electronics provided format
  • Historically, measures of sustained attention are
    intrical to the history of psychology
  • Study cited as the basis for the origin of cpts
    is Rosvold, Mirsky, Sarason, Bransome Beck
    (1956). A continuous performance test of brain
    damage. Journal of Consulting Psychology, 20,
    3343-350.

51
Background History
  • For the Rosvold et al study (1956) the purpose
    was to study vigilance.
  • The designed task was for a letter to appear one
    at a time using a fixed rate of presentation
    (ISI) at 920 ms.
  • Press the lever whenever the letter x appeared

52
Background History
  • The subject also had another task - to inhibit
    responding when any other letter appeared.
  • Task became known as the X type cpt
  • Rosvold et al (1956) also reported use of a
    second type cpt the AX-type
  • For this task, the subject was to press the lever
    if a letter A preceded the letter X

53
Continuous Performance Tests
  • Still needed to inhibit action
  • Authors found the task to adequately classify
    84.2 to 89.5 of younger subjects who had brain
    damage
  • Greater classification was for AX-type

54
Continuous Performance Tests
  • Since this study - have been literally hundreds
    of studies utilizing a cpt task of some sort-
    also report Riccio,Reynolds Lowe (2001) over
    400 articles using cpts
  • Riccio et al (2001) reported finding 162 research
    studies using some form of group comparison with
    children and some sort of cpt task

55
Continuous Performance Tests
  • Research studies may use a cpt designed only for
    that study
  • lacking normative development
  • increased difficulty with study replication
  • Easy to program (if you find programming easy)
  • Many variations of design

56
Continuous Performance Tests
  • Cpt variations
  • stimulus presentation
  • interval of stimulus
  • stimulus modality
  • distraction modes
  • adaptive cpts
  • length of task
  • target/nontarget ratio

57
Variations of CPTs
  • Stimulus Presentation
  • X- type (easier task)
  • AX- type (more difficult task)
  • XX-type
  • Numeric (variation of X or AX type)
  • GDS uses numeric stimulus
  • 1 - 9 type task (number 1 followed by number 9)

58
Variations of CPTs
  • Interstimulus Interval (ISI) variations
  • Rosvold et al (1956) used 920 ms
  • some have used from 50 to 1500 ms (Friedman,
    Vaughan Erlenmeyer-Kimling (1981)
  • 500 to 1500 ms (Schachar, Logan, Wachsmuth
    Chajczyk, 1988)
  • some tasks maintain consistent ISI
  • others use variable ISI within task

59
Variations of CPTs
  • Other component related to ISI is that of
    stimulus onset asynchrony (SOA)
  • This refers to the onset of the stimulus followed
    by the onset of the next stimulus
  • i.d., stimulus may linger longer allowing task
    recognition
  • some cpts use variable SOA, others consistent SOA

60
Variations of CPTs
  • ISI - SOA
  • increase ISI decrease SOA
  • shorter SOA may increase mis-hits
  • shorter SOA may increase omissions
  • increase ISI increase SOA
  • slower response times

61
Variations of CPTs
  • Stimulus Modality (Visual/Auditory)
  • Non-alphanumeric
  • Square within square (T.O.V.A.)
  • Rabbit (in development)
  • Auditory stimulus presentation models
  • auditory X or AX types
  • auditory numeric
  • tones (T.O.V.A.-A.)

62
Variations of CPTs
  • Distraction
  • these cpts use X or AX-type then add another
    dimension interference or distraction
  • goal is to increase level of difficulty
  • distraction task varies by cpt
  • degraded or blurred
  • visual distractions common for visual X or AX
    cpts
  • auditory distractions

63
Variations of CPTs
  • Adaptive cpts
  • increase level of difficulty as success of task
    accomplished and maintained

64
Variations of CPTs
  • Length of task
  • Bremer (1989) reported mini-cpt
  • 3 minute task
  • 6 minute task available
  • T.O.V.A./T.O.V.A.-A
  • longest
  • 21.6 minutes

65
Variations of CPTs
  • Target/nontarget ratio
  • refers to presentation of targets to nontargets
    throughout task
  • some use variable others consistent
  • some use variable mixed with variable ISI

66
Comments
  • Influences on cpt performance
  • directions
  • examiner presence
  • anxiety, depression and the rest of DSM-IV
  • drugs and alcohol (including caffeine)
  • environmental distractions

67
The Big 4
  • 4 major cpts have emerged within the marketplace
  • all report normative and standardization
  • Alphabetical order
  • Conners CPT (The cpt??)
  • GDS
  • IVA
  • T.O.V.A./T.O.V.A.-A.

68
The Big 4
  • Conners CPT
  • Available from Multihealth Systems, Inc (MHS)
  • www.mhs.com
  • 800.456.3033
  • may be available from other distributors such
    as PAR or WPS

69
The Big 4
  • ConnersCPT
  • Type not x
  • Modality Visual
  • Stimulus display 250 ms
  • ISI varied 1000 to 4000 ms
    (varied within block)

70
The Big 4
  • Conners CPT
  • Target Letter
  • Length 14 minutes
  • Nontargets letters
  • Distraction none
  • Target ratio not varied

71
The Big 4
  • Conners CPT
  • Block Timing yes
  • Customized available
  • Examiner presence ?
  • Practice trials yes
  • Standardized instructions yes

72
The Big 4
  • Conners CPT Scoring
  • correct hits
  • omission/commission errors
  • d-prime/beta
  • reaction time
  • reaction time standard deviation

73
The Big 4
  • ConnersCPT Scoring
  • slope of standard error
  • slope at ISI change
  • slope of standard error at ISI change
  • overall performance index

74
The Big 4
  • GDS Gordon Diagnostic System
  • Available from Gordon Systems, Inc.
  • www.gsi.com
  • 800.550.2343
  • note may be available from other distributors
    such as PAR, WPS

75
The Big 4
  • GDS
  • Type AX(numeric)
  • Modality Visual
  • Stimulus display 200 ms
  • ISI 1000/2000 ms
  • (children adults/preschool)

76
The Big 4
  • GDS
  • Target number
  • Length 9 minutes/6 for preschool
  • Nontargets numbers
  • Distraction yes
  • Target ratio not varied

77
The Big 4
  • GDS
  • Block Timing yes
  • Customized available
  • Examiner presence yes
  • Practice trials yes

78
The Big 4
  • GDS Scoring
  • correct hits
  • omission/commission errors
  • reaction time
  • target related error / random error

79
The Big 4
  • Intermediate Visual and Auditory CPT (IVA) also
    known as Integrated Visual Auditory CPT
  • Available from BrainTrain
  • www.braintrain-online.com
  • 804.320.0105
  • Note May also be available from other
    distributors such as PAR, WPS

80
The Big 4
  • IVA
  • Type X
  • Modality Visual auditory in same task
  • Stimulus Display 167 auditory/500 visual
  • ISI 1500 ms

81
The Big 4
  • IVA
  • Target number
  • Length 13
  • Nontargets numbers
  • Distraction no?
  • Target ratio varied

82
The Big 4
  • IVA
  • Block Timing yes
  • Customized no
  • Examiner presence yes
  • Practice trials yes

83
The Big 4
  • IVA Scoring
  • response control quotient (auditory,visual, full)
  • attention quotient (auditory, visual, full)
  • auditory visual prudence scores
  • vigilance
  • consistency
  • stamina

84
The Big 4
  • IVA Scoring
  • focus
  • speed
  • balance
  • persistence
  • fine motor/hyperactivity

85
The Big 4
  • IVA Scoring
  • sensoriomotor
  • readiness
  • comprehension

86
The Big 4
  • Test of Variables of Attention (T.O.V.A.) Test
    of Variables of Attention-Auditory (T.O.V.A.-A.)
  • Available from Universal Attention Disorders,
    Inc.
  • www.tovatest.com
  • 800.729.2886 (800-PAY-ATTN)
  • Note Also available from other distributors
    such as PAR, WPS

87
The Big 4
  • T.O.V.A./T.O.V.A.-A.
  • Type X
  • Modality Visual/Auditory
  • Stimulus display 100 ms
  • ISI 2000 ms

88
The Big 4
  • T.O.V.A./T.O.V.A.-A.
  • Target position of square
  • Length 21.6 mins
  • Nontargets position of square
  • Distraction no
  • Target ratio varied

89
The Big 4
  • T.O.V.A./T.O.V.A.-A.
  • Block Timing yes
  • Customized yes
  • Examiner presences yes
  • Practice trials yes

90
The Big 4
  • T.O.V.A./T.O.V.A.-A. Scoring
  • omission/commission errors
  • response time
  • response time variability
  • d prime

91
The Big 4
  • T.O.V.A./T.O.V.A.-A. Scoring
  • multiple responses
  • anticipatory Responses
  • ADHD scale
  • post commission error response time

92
T.O.V.A.
  • Non-language based stimulus
  • X-type
  • Square within square stimulus
  • Square at top target
  • Square at bottom - nontarget

93
T.O.V.A.
  • T.O.V.A.-A. uses two tones
  • Middle c non-target
  • G above middle C target
  • Consistent with paradigm top is the target

94
T.O.V.A.
  • Standardized instructions to be given in
    language appropriate for subject (native)
  • Examiner must be present standardization group
    did have examiner present
  • Prompt for subject to respond as quickly as
    possible when sees target

95
T.O.V.A.
  • Separate standardization samples
  • Over 2500 subjects in T.O.V.A.-A.
  • Age 6 above
  • Ages 19-30
  • Over 2000 subjects in T.O.V.A.
  • Age 4-5 11.3 minute version
  • One quarter of target frequent/infrequent

96
T.O.V.A.
  • T.O.V.A.
  • One year age increments ages 6 to 19
  • Data by gender
  • Ages 20 above by decade
  • Data by gender

97
T.O.V.A.
  • Two conditions target infrequent target
    frequent
  • 3.51 non-targets for every target (infrequent)
  • 3.51 targets for every non-target (frequent)
  • Stimuli presented in a fixed random model

98
T.O.V.A.
  • Quarter 1 2 target infrequent
  • Subject who is inattentive likely to miss target
  • Measure of attention
  • Omission errors likely
  • Quarter 3 4 target frequent
  • Subject who is impulsive likely to mis-hit
  • Measure of impulse control
  • Commission errors likely

99
T.O.V.A.
  • Scores presented by quarters, halves total for
    each variable
  • Scoring uses derived standard scores, 100 mean,
    15 standard deviation
  • Higher scores reflect better performance, lower
    scores reflect poorer performance

100
T.O.V.A.
  • In addition
  • Z scores
  • Percentiles for RT RTV
  • Anticipatory errors
  • Responses presented from 200 ms prior to stimulus
    onset to 200 ms after onset

101
T.O.V.A.
  • Multiple Responses pressing button more than
    once
  • Post-Commission Response Time following
    commission error, response time for next correct
    target identification is recorded

102
T.O.V.A.
  • Multiple responses rare in standardization group
  • Increased multiple responses decrease validity of
    subject performance
  • Error Analysis examiner is able to review all
    responses to all stimuli over duration of test

103
T.O.V.A.
  • ADHD score
  • Based upon ROC discriminant function analysis
  • Best 3 predictors for placing subjects in ADHD
    prediction group
  • Uses subject z scores

104
T.O.V.A.
  • ADHD score
  • Scores less than or equal to zero (0) indicate
    subject more likely to be placed in ADHD group
  • Scores above zero (0) indicates subjects less
    likely to be placed in ADHD group
  • NOTE RECALL THAT Z SCORES ARE USED TO DERIVE
    SCORES

105
T.O.V.A.
  • D Prime
  • Measure of performance consistency over duration
    of task
  • Beta not found to be significant between groups,
    thus is not reported

106
T.O.V.A.
  • Construct validity
  • Actual
  • Predicted Normal ADHD
  • Normal 75 25
  • ADHD 23 77
  • Leark, R.A., Dixon, D., Llorentes, A., Allen, M.
    (2000) Cross-validation Performance
    Discriminant Abilities of the T.O.V.A. using
    DSM-IV criteria. Poster presentation at the 20th
    Annual Meeting of the National Academy of
    Neuropsychology. Orlando, FL.

107
T.O.V.A.
  • Sensitive to malingering
  • Increased errors across all 4 quarters, both
    halves and total score for omission commission
  • Decreased response time
  • Increased variability of response time
  • Leark, R.A., Dixon, D., Hoffman, T. Hunyh,
    D.(in press). Effects of Fake Bad performance on
    the T.O.V.A. Archives of Clinical Neuropsychology

108
T.O.V.A.
  • Relationship to IQ
  • Greenberg has reported need to adjust T.O.V.A.
    scores for IQ
  • HOWEVER Research has indicated this to be a
    false assumption

109
T.O.V.A.
  • Chae (1999)
  • T.O.V.A. not found to be significantly correlated
    with VIQ/PIQ/FSIQ
  • PIQ/FSIQ is moderately related to Omission total
    scores ( .46 .44)
  • Picture Arrangement Object Assembly correlated
    at -.50 -.54

110
T.O.V.A.
  • Chae (1999)
  • Freedom from Distractibility factor not
    significantly correlated
  • Processing Speed factor not significantly
    correlated

111
T.O.V.A.
  • Other studies have reported similar findings
  • At best there is approximately a .50 correlation
    between FSIQ and T.O.V.A. scores
  • Third factor not significantly correlated with
    T.O.V.A. scores
  • IQ not factor in T.O.V.A. performance

112
T.O.V.A.
  • Construct validity for T.O.V.A.-A
  • ADHD (DSM-IV) to normal control children
  • Diagnosis independent of T.O.V.A.-A. performance
  • All subjects correctly classified using z scores
  • Leark, R.A., Golden, C.J., Escalande, A. Allen,
    M. (2001) Initial Dicriminant Abilities of the
    T.O.V.A.-A. Poster paper presented at the 21st
    Annual Meeting of the National Academy of
    Neuropsychology

113
T.O.V.A.
  • Temporal Stability of T.O.V.A.
  • Internal coefficients not appropriate for timed
    tasks
  • Temporal stability reasonable time interval
  • 90 minutes
  • 1 week

114
T.O.V.A.
  • 90 Minute Interval
  • Scale coefficient
  • Omission 0.80
  • Commission 0.78
  • RT 0.93
  • RTV 0.77

115
T.O.V.A.
  • 1 Week Interval
  • Scale Coefficient
  • Omission 0.86
  • Commission 0.74
  • RT 0.79
  • RTV 0.87

116
T.O.V.A.
  • Sem
  • Scale 90 Minute 1 Week
  • Omission 6.71 5.61
  • Commission 7.04 7.65
  • RT 3.97 6.87
  • RTV 7.19 5.41
  • Note reflects T-scores

117
T.O.V.A.
  • Relationship to behavioral rating scales
  • Forbes (1998) reported that the T.O.V.A. provided
    distinct information that added to increased
    diagnostic accuracy
  • Correlation studies have report significant but
    moderate correlations between behavioral measures
    and test variables

118
T.O.V.A.
  • Forbes (1998)
  • ACTers Hyper OM -.37 COM -.30
  • Oppos OM -.38 COM -.25
  • Attn OM -.25 COM -.16

119
T.O.V.A.
  • Selden, Pospisil, Michael Golden (2001)
  • CBCL-TRF Attention Index
  • ADHD score .393
  • TOVA-A COM .372
  • CPRS Hyperactivity Scale
  • TOVA OM .423
  • PIC-R Hyperactivity Scale
  • TOVA COM .325

120
T.O.V.A.
  • Continuous Performance Test (CPT)
  • measure of sustained attention vigilance
  • measure of impulse control
  • long, boring measures

121
T.O.V.A.
  • Test of Variables of Attention (Greenberg, 1992)
  • T.O.V.A. non-language stimulus task
  • computer based
  • fixed two second interstimulus interval (ISI)
  • 21.6 minute long task

122
T.O.V.A.
123
T.O.V.A.
  • two task paradigms target infrequent target
    frequent
  • a constant 3.51 ratio
  • Target Infrequent 3.5 1 non-targets to targets
  • Target Frequent 3.51 targets to non-targets

124
T.O.V.A.
  • Internally clocked
  • Data summarized into quarters, halves and total
    score
  • Quarters 1 2 - target infrequent
  • Quarters 3 4 - target frequent
  • Half 1 - target infrequent
  • Half 2 - target frequent

125
T.O.V.A.
  • Extensive norm development over 2300 subjects
  • Scaled by age and gender
  • Uses derived standard scores with mean of 100,
    standard deviation of 15
  • z scores also provided

126
T.O.V.A.
  • T.O.V.A. Scales
  • Omission - measure of attention/inattention
  • Commission - measure of impulse control
  • Response Time - in milliseconds
  • Response Time Variability - measure of response
    consistency
  • d (d prime) - signal detection measure response
    consistency

127
T.O.V.A.
  • Established construct and disciminant validity
  • Established reliability 90 minute, 1 week, 8
    week and 12 week intervals
  • Established sensitivity specificity (80/20)

128
T.O.V.A.
  • Semrud-Clikeman Wical (1999)
  • evaluated attentional difficulties in children
    with complex partial seizures (CPS), CPS ADHD,
    CPS without ADHD, and controls
  • used T.O.V.A. as measure of sustained attention
    impulse control
  • Components of Attention in Children with Complex
    Partial Seizures with and without ADHD. Epilepsy,
    40(2) 211-215.

129
T.O.V.A.
  • Semrud-Clikeman Wical (1999) Results
  • Found poorest performance on the T.O.V.A. by the
    CPS/ADHD group.
  • Difficulty in attention was noted for children
    with epilepsy regardless of ADHD
  • When methylphenidate was administered to the ADHD
    groups - both improved on T.O.V.A. scores

130
T.O.V.A.
  • Semrud-Clikeman Wical (1999)
  • Conclusions
  • Epilepsy may dispose children to attention
    problems that can significantly impair with
    learning
  • Improvement, as measured by improved T.O.V.A.
    measures was found for both ADHD groups when
    methylphenidate was administered

131
T.O.V.A.
  • Mautner, Thakkar, Kluwe Leark (in press)
  • NF1, NF1 with ADHD, ADHD controls
  • NF1 with ADHD ADHD similar
  • over 15 of the NF1 participants displayed
    symptoms of ADHD
  • Both the NF1 with ADHD and the ADHD subjects had
    improved T.O.V.A. scores when methylphenidate was
    administered
  • Treatment of ADHD in NF1 Type 1. Developmental
    Medicine

132
Clinical Care
  • Treatment considerations
  • Medications
  • methylphenidate hydrochloride
  • Ritalin
  • Sustained Release
  • Concerta
  • Amphetamines
  • Adderall
  • Dexedrine

133
Clinical Care
  • Treatment considerations
  • Medication Issues
  • kg/mg - is this an appropriate method for
    titration?
  • Titration to cognitive measures produces an
    overall lower mean dosage than for behavioral
    measures
  • b.i.d. or t.i.d.
  • Dosage?
  • Time of day?

134
Clinical Care
  • Treatment considerations
  • Behavioral Treatment
  • home and classroom based intervention strategies
  • requires cooperation of parents teachers
  • effective - but best when used with medication

135
Clinical Care
  • Treatment considerations
  • Family Therapies
  • Family system with behavioral interventions for
    child
  • Does require intact family system

136
Clinical Care
  • Treatment considerations
  • Stimulant medication is standard of care
  • NIMH revenue of ADHD studies suggested that
  • Stimulant medication alone better than stimulant
    medication and behavioral therapy, behavioral
    therapy alone or placebo.

137
References
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