Robert A. Leark, Ph.D. Fellow, National Academy of Neuropsychology
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Transcript of Robert A. Leark, Ph.D. Fellow, National Academy of Neuropsychology
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Robert A. Leark, Ph.D.Fellow, National Academy of NeuropsychologyAssociate Professor, Behavioral & Social SciencesPacific Christian College, Fullerton, CAVice President, Research & Development, UAD., Inc
Theoretical Models of Explanation
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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
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Theoretical Models of Explanation
Recent Historical Models Attention is not a unitary construct Zubin (1995): attention conceptualized
as having multiple components or elements
Psychiatric models:attention is process that controls the flow of information processing
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Theoretical Models of Explanation
Recent Historical Models Psychiatric models: 3 components of
attention:selectivitycapacitysustained concentrationAll of these must be sufficient enough to
interfere with daily activities
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Theoretical Models of Explanation
Recent Historical Models Neuropsychologists typically
conceptualize attention as:selective processingawareness of stimuli
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Theoretical Models of Explanation
Recent Historical Models Neuropsychologists use attention to
refer to:initiation or focusing of attentionsustaining attention or vigilanceinhibiting response to irrelevant stimuli
(selective attention)shifting of attention
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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/concentrationShifting of attention
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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.)
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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
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Theoretical Models of Explanation
Historical Mirsky (1987) proposed three factor
model for attentionfocusing of attentionsustaining of attentionshifting of attention
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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
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Theoretical Models of Explanation
Historical Luria’s model
attention central to model2 attentional systems: reflexive & nonreflexivereflexive: orienting response/appears early in
developmentnonreflexive: result of social learning/develops
slowerlimbic system & frontal lobe mediate attention
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Theoretical Models of Explanation
Historical Luria’s model
executive functions linked to mediating attention
executive functions:• self-direction• goal directedness• self-regulation• response selection• response inhibition
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Theoretical Models of Explanation
Mesulam (1981): model similar to Luria’s 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
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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
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Theoretical Models of Explanation
Historical Summary: attention involves at least
two separate neural systemsactivation 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
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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
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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
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Theoretical Models of Explanation
Barkley & Gordon (1994,1997,1998,2001)
basal ganglia dopaminergic disinhibition key factor to etiology
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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
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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
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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 Brown’s rating scale: BADDS - modeled
upon this theoretical approach
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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
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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
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Clinical Care
History - conception through current age early life predictors
poor or inability to establish early life routinesmotor hyperactivity at early age
ADHD is a diagnosis by exclusion:low APGARhypoxiacentral nervous system diseases
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Issues in Clinical Care
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Clinical CareHistory
ADHD is a diagnosis by exclusion:head injury/loss of consciousnessmetabolic disordersseizure disordersapneaother medical conditionsOther psychiatric conditions
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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
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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
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Clinical Care
Diagnostic procedures
Behavioral rating scales Measure of sustained attention &
impulse control Medication follow-up
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Clinical Care
Behavior Rating Scales Child-Behavior Checklist (CBCL)
Parent RatingTeacher RatingItem pure scales: no item overlap
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Clinical Care
Behavior Rating Scales BASC (Reynolds & Kamphaus)
Ages 2 - 18Item pure scales: no item overlapeasy to administershorter: about 140 items
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Clinical Care
Behavior Rating Scales BASC (Reynolds & Kamphaus)
2-6: parent/other ratings7-12: self rating
parent rating teacher rating student observation guide
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Clinical Care
Behavior Rating Scales BASC (Reynolds & Kamphaus)
13-18: self parent
teacher student observation guide
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Clinical Care
Behavior Rating Scales BASC (Reynolds & Kamphaus)
New: ADHD predictorderived from discriminant function analysis using best predictors
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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
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Clinical Care IssuesTreatment Issues
Treatment consistent with theoretical models for ADHD?
NIMH Treatment GuidelinesMedication effective, data indicated
medication alone more effective than• Medication & behavioral treatment• Behavioral treatment alone• Other modalities
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Clinical Care IssuesBehavioral therapies
Treatment goal: improve/increase inhibition Treatment strategies must be consistent
with goalTreatment strategies must be incorporated
into family system• Often source of increase problems if family not
stable• Noncompliance by parents
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Clinical Care IssuesNewer treatment modalities
NeurofeedbackIssues:standardization of treatmentLength of treatmentTreatment cessation: maintenance of gains
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Clinical CareTreatment considerations
Stimulant medication is standard of care NIMH revenue of ADHD studies
suggested thatStimulant medication alone better
than stimulant medication and behavioral therapy, behavioral therapy alone or placebo.
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Clinical CareTreatment considerations
Medicationsmethylphenidate hydrochloride
• Ritalin• Sustained Release• Concerta
Amphetamines• Adderall• Dexedrine
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Clinical CareTreatment considerations
Medication Issueskg/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?
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Clinical CareTreatment considerations
Behavioral Treatmenthome and classroom based
intervention strategiesrequires cooperation of parents &
teacherseffective - but best when used with
medication
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Clinical CareTreatment considerations
Family TherapiesFamily system with behavioral interventions
for childDoes require intact family system
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Clinical CareTreatment considerations
Stimulant medication is standard of care NIMH revenue of ADHD studies
suggested thatStimulant medication alone better
than stimulant medication and behavioral therapy, behavioral therapy alone or placebo.
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Clinical Care IssuesSummary: treatment goals and plans
need to be consistent with theoretical models of ADHD
Medication: ritalin, adderall, others
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Clinical Care IssuesSummary: treatment goals and plans
need to be consistent with theoretical models of ADHD
Medication: ritalin, adderall, others
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Continuous performance tests
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Grew out of need to provide for a measurement of attention and impulse control
Wanted actual measurement not behavioral attributes
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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.
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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
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Background & History
The subject also had another task - to inhibit responding when any other letter appeared.
Task became known as the X type cptRosvold et al (1956) also reported use
of a second type cpt: the AX-typeFor this task, the subject was to press
the lever if a letter A preceded the letter X
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Continuous Performance Tests
Still needed to inhibit actionAuthors found the task to adequately
classify 84.2% to 89.5% of younger subjects who had brain damage
Greater classification was for AX-type
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Continuous Performance TestsSince 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
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Continuous Performance Tests
Research studies may use a cpt designed only for that study lacking normative development increased difficulty with study
replicationEasy to program (if you find
programming easy)Many variations of design
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Continuous Performance Tests
Cpt variations stimulus presentation interval of stimulus stimulus modality distraction modes adaptive cpts length of task target/nontarget ratio
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Variations of CPTsStimulus Presentation
X- type (easier task) AX- type (more difficult task) XX-type Numeric (variation of X or AX type)
GDS uses numeric stimulus1 - 9 type task (number 1 followed by
number 9)
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Variations of CPTsInterstimulus 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
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Variations of CPTsOther 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
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Variations of CPTsISI - SOA
increase ISI decrease SOAshorter SOA may increase “mis-hits” shorter SOA may increase omissions
increase ISI increase SOAslower response times
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Variations of CPTsStimulus Modality (Visual/Auditory)
Non-alphanumeric Square within square (T.O.V.A.)Rabbit (in development)
Auditory stimulus presentation modelsauditory X or AX typesauditory numerictones (T.O.V.A.-A.)
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Variations of CPTsDistraction
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 blurredvisual distractions common for visual X or AX cptsauditory distractions
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Variations of CPTsAdaptive cpts
increase level of difficulty as success of task accomplished and maintained
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Variations of CPTsLength of task
Bremer (1989) reported “mini-cpt”3 minute task6 minute task available
T.O.V.A./T.O.V.A.-Alongest21.6 minutes
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Variations of CPTsTarget/nontarget ratio
refers to presentation of targets to nontargets throughout task
some use variable others consistent some use variable mixed with variable
ISI
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CommentsInfluences on cpt performance
directions examiner presence anxiety, depression and the rest of
DSM-IV drugs and alcohol (including caffeine) environmental distractions
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The Big 44 major cpts have emerged within the
marketplaceall report normative and
standardizationAlphabetical order:
Conners’ CPT (“The cpt”??) GDS IVA T.O.V.A./T.O.V.A.-A.
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The Big 4Conners’ CPT
Available from Multihealth Systems, Inc (MHS)*
www.mhs.com 800.456.3033
* may be available from other distributors such as PAR or WPS
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The Big 4Conners’CPT
Type: not x Modality: Visual Stimulus display 250 ms ISI varied 1000 to
4000 ms (varied
within block)
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The Big 4Conners’ CPT
Target Letter Length 14 minutes Nontargets letters Distraction none Target ratio not varied
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The Big 4Conners’ CPT
Block Timing yes Customized available Examiner presence ? Practice trials yes Standardized instructions yes
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The Big 4Conners’ CPT Scoring
correct hits omission/commission errors d-prime/beta reaction time reaction time standard deviation
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The Big 4Conners’CPT Scoring
slope of standard error slope at ISI change slope of standard error at ISI change overall performance index
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The Big 4GDS: 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
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The Big 4GDS
Type AX(numeric) Modality Visual Stimulus display 200 ms ISI 1000/2000 ms
(children adults/preschool)
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The Big 4GDS
Target number Length 9 minutes/6 for preschool Nontargets numbers Distraction yes Target ratio not varied
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The Big 4GDS
Block Timing yes Customized
available Examiner presence yes Practice trials yes
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The Big 4GDS Scoring
correct hits omission/commission errors reaction time target related error / random error
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The Big 4Intermediate 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
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The Big 4IVA
Type X Modality Visual & auditory in same
task Stimulus Display 167 auditory/500
visual ISI 1500 ms
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The Big 4IVA
Target number Length 13 Nontargets numbers Distraction no? Target ratio varied
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The Big 4IVA
Block Timing yes Customized no Examiner presence yes Practice trials yes
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The Big 4IVA Scoring
response control quotient (auditory,visual, full)
attention quotient (auditory, visual, full) auditory & visual prudence scores vigilance consistency stamina
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The Big 4IVA Scoring
focus speed balance persistence fine motor/hyperactivity
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The Big 4IVA Scoring
sensoriomotor readiness comprehension
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The Big 4Test 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
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The Big 4T.O.V.A./T.O.V.A.-A.
Type: X Modality: Visual/Auditory Stimulus display 100 ms ISI 2000 ms
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The Big 4T.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
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The Big 4T.O.V.A./T.O.V.A.-A.
Block Timing yes Customized yes Examiner presences yes Practice trials yes
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The Big 4T.O.V.A./T.O.V.A.-A. Scoring
omission/commission errors response time response time variability d prime
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The Big 4T.O.V.A./T.O.V.A.-A. Scoring
multiple responses anticipatory Responses ADHD scale post commission error response time
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T.O.V.A.Non-language based stimulusX-typeSquare within square stimulusSquare at top – targetSquare at bottom - nontarget
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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
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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
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T.O.V.A.Separate standardization samplesOver 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
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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
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T.O.V.A.Two conditions: target infrequent &
target frequent3.5:1 non-targets for every target
(infrequent)3.5:1 targets for every non-target:
(frequent)Stimuli presented in a fixed random
model
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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
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T.O.V.A.Scores presented by quarters, halves
& total for each variableScoring uses derived standard
scores, 100 mean, 15 standard deviation
Higher scores reflect better performance, lower scores reflect poorer performance
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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
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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
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T.O.V.A.Multiple responses rare in
standardization group Increased multiple responses decrease
validity of subject performanceError Analysis: examiner is able to
review all responses to all stimuli over duration of test
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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
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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
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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
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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.
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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
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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
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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
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T.O.V.A.Chae (1999)
Freedom from Distractibility factor not significantly correlated
Processing Speed factor not significantly correlated
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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
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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.
performanceAll subjects correctly classified using z
scoresLeark, 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
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T.O.V.A.Temporal Stability of T.O.V.A.
Internal coefficients not appropriate for timed tasks
Temporal stability: reasonable time interval90 minutes1 week
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T.O.V.A.90 Minute Interval
Scale coefficientOmission 0.80Commission 0.78RT 0.93RTV 0.77
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T.O.V.A.1 Week Interval
Scale Coefficient Omission 0.86 Commission 0.74 RT 0.79 RTV 0.87
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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
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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
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T.O.V.A.Forbes (1998)
ACTers Hyper OM -.37 COM -.30 Oppos OM -.38 COM -.25 Attn OM -.25 COM -.16
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T.O.V.A.Selden, Pospisil, Michael & Golden
(2001)CBCL-TRF Attention Index
ADHD score .393TOVA-A COM .372
CPRS Hyperactivity ScaleTOVA OM .423
PIC-R Hyperactivity ScaleTOVA COM .325
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T.O.V.A.
Continuous Performance Test (CPT)
measure of sustained attention & vigilance
measure of impulse control long, boring measures
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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
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T.O.V.A.
Nontarget Target
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T.O.V.A.
two task paradigms: target infrequent & target frequent
a constant 3.5:1 ratio Target Infrequent: 3.5: 1 non-targets to
targets Target Frequent: 3.5:1 targets to non-
targets
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T.O.V.A.
Internally clocked Data summarized into quarters,
halves and total scoreQuarters 1 & 2 - target infrequent Quarters 3 & 4 - target frequentHalf 1 - target infrequentHalf 2 - target frequent
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T.O.V.A.
Extensive norm development: over 2300 subjects
Scaled by age and genderUses derived standard scores with
mean of 100, standard deviation of 15
z scores also provided
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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
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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)
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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.
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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
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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
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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
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Clinical CareTreatment considerations
Medicationsmethylphenidate hydrochloride
• Ritalin• Sustained Release• Concerta
Amphetamines• Adderall• Dexedrine
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Clinical CareTreatment considerations
Medication Issueskg/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?
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Clinical CareTreatment considerations
Behavioral Treatmenthome and classroom based
intervention strategiesrequires cooperation of parents &
teacherseffective - but best when used with
medication
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Clinical CareTreatment considerations
Family TherapiesFamily system with behavioral interventions
for childDoes require intact family system
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Clinical CareTreatment considerations
Stimulant medication is standard of care NIMH revenue of ADHD studies
suggested thatStimulant medication alone better
than stimulant medication and behavioral therapy, behavioral therapy alone or placebo.
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References