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Robert A. Leark, Ph.D. Fellow, National Academy of Neuropsychology Associate Professor, Behavioral & Social Sciences Pacific Christian College, Fullerton,

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Presentation on theme: "Robert A. Leark, Ph.D. Fellow, National Academy of Neuropsychology Associate Professor, Behavioral & Social Sciences Pacific Christian College, Fullerton,"— Presentation transcript:

1 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 Theoretical Models of Explanation

2 zMultiple models of explanation for ADHD zTwo have emerged as primary theories yBarkley & Gordon yBrown zAttention & executive functioning is multifaceted: difficult to map

3 Theoretical Models of Explanation zRecent Historical Models yAttention is not a unitary construct yZubin (1995): attention conceptualized as having multiple components or elements yPsychiatric models:attention is process that controls the flow of information processing

4 Theoretical Models of Explanation zRecent Historical Models yPsychiatric models: 3 components of attention: xselectivity xcapacity xsustained concentration xAll of these must be sufficient enough to interfere with daily activities

5 Theoretical Models of Explanation zRecent Historical Models yNeuropsychologists typically conceptualize attention as: xselective processing xawareness of stimuli

6 Theoretical Models of Explanation zRecent Historical Models yNeuropsychologists use attention to refer to: xinitiation or focusing of attention xsustaining attention or vigilance xinhibiting response to irrelevant stimuli (selective attention) xshifting of attention

7 Theoretical Models of Explanation zRiccio, Reynolds & Lowe (2001) summarize components of attention xArousal/alertness motor intention/initiation xSelective Attention focusing of attention (inhibiting/filtering) divided attention encoding, rehearsal & retrieval xSustaining attention/concentration xShifting of attention

8 Theoretical Models of Explanation zHistorical yBroadbent (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 zHistorical y2nd model stresses arousal - here optimal arousal (alertness) is necessary for effortful, organized function (Hebb, 1958) yPribram (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 zHistorical yMirsky (1987) proposed three factor model for attention xfocusing of attention xsustaining of attention xshifting of attention

11 Theoretical Models of Explanation zHistorical yMirsky model xselective attention: part of process of focusing attention (level of distractibility if deficient) xSustained attention: ability to maintain that focus over time xShifting of attention: necessary for adaptation & inhibition

12 Theoretical Models of Explanation zHistorical yLuria’s model xattention central to model x2 attentional systems: reflexive & nonreflexive xreflexive: orienting response/appears early in development xnonreflexive: result of social learning/develops slower xlimbic system & frontal lobe mediate attention

13 Theoretical Models of Explanation zHistorical yLuria’s model xexecutive functions linked to mediating attention xexecutive functions: self-direction goal directedness self-regulation response selection response inhibition

14 Theoretical Models of Explanation zMesulam (1981): model similar to Luria’s yModel was specific to understanding phenomenon of hemiattention or hemineglect as result of brain damage yAttentional processes: reticular system, limbic system, frontal cortex & posterior parietal cortex

15 Theoretical Models of Explanation zMesulam (1981) ySubcortical influences from limbic system, RAS & hypothalamus part of system matrix needed for control of attention yFrontal lobes influenced by & also influence the subcortical activity

16 Theoretical Models of Explanation zHistorical ySummary: attention involves at least two separate neural systems xactivation system: thought to be centered in left hemisphere & involved in sequential/analytic operations xarousal: thought to be centered in right hemisphere & involved in parallel or holistic processing & maintenance of attention

17 Theoretical Models of Explanation zBarkley & Gordon (1994,1997,1998,2001) yinattention emerges alongside a general pattern of impulsiveness & hyperactivity ydeficits in self-control lead to secondary impairments in four executive functions

18 Theoretical Models of Explanation zBarkley & Gordon (1994,1997,1998,2001) yNonverbal working memory - sensing to the self yverbal working memory - internalized speech yemotional/motivation self regulation - private emotion/motivation to the self yreconstruction or generativity - cover play & behavioral simulation to the self

19 Theoretical Models of Explanation zBarkley & Gordon (1994,1997,1998,2001) ybasal ganglia ydopaminergic ydisinhibition key factor to etiology

20 Theoretical Models of Explanation zBarkley & Gordon (2001) yADHD is a longstanding, pervasive and chronically impairing consequence of poor inhibition and/or inattention ymodel is consistent with the DSM-Ivr criteria ysymptoms occur prior to age 7

21 Theoretical Models of Explanation zBrown (1996) yetiology is on purely inattentive ystresses there has been an over-focus on disinhibition and an under appreciation of arousal, activation and working memory yonset of symptoms can occur after age 7

22 Theoretical Models of Explanation zBrown yADHD criteria includes inattentive individuals who are not impulsive y“all inattention is ADD/ADHD” yADHD is a suitable diagnosis for a broad range of symptoms yBrown’s rating scale: BADDS - modeled upon this theoretical approach

23 Theoretical Models of Explanation zBrown - ADD/ADHD is still an executive dysfunction of five clusters yorganizing & activating to work ysustaining attention & concentration ysustaining energy & effort ymanaging affective interference yutilizing working memory & recall

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

25 Clinical Care zHistory - conception through current age yearly life predictors xpoor or inability to establish early life routines xmotor hyperactivity at early age yADHD is a diagnosis by exclusion: xlow APGAR xhypoxia xcentral nervous system diseases

26 Issues in Clinical Care

27 Clinical Care zHistory yADHD is a diagnosis by exclusion: xhead injury/loss of consciousness xmetabolic disorders xseizure disorders xapnea xother medical conditions xOther psychiatric conditions

28 Clinical Care zHistory yADHD is a diagnosis by exclusion: xADHD is diagnosed only when other disorders do not best account for the symptoms xsymptoms may be same, etiology somewhat different (or unknown) xtreatment may even be the same

29 Clinical Care zHistory yProblems with overlapping co-morbidity create need to be able to stick to DSM IV criteria: age 7 issue yMay 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 zDiagnostic procedures yBehavioral rating scales yMeasure of sustained attention & impulse control yMedication follow-up

31 Clinical Care zBehavior Rating Scales yChild-Behavior Checklist (CBCL) xParent Rating xTeacher Rating xItem pure scales: no item overlap

32 Clinical Care zBehavior Rating Scales yBASC (Reynolds & Kamphaus) xAges xItem pure scales: no item overlap xeasy to administer xshorter: about 140 items

33 Clinical Care zBehavior Rating Scales yBASC (Reynolds & Kamphaus) x2-6: parent/other ratings x7-12: self rating parent rating teacher rating student observation guide

34 Clinical Care zBehavior Rating Scales yBASC (Reynolds & Kamphaus) x13-18: self parent teacher student observation guide

35 Clinical Care zBehavior Rating Scales yBASC (Reynolds & Kamphaus) xNew: ADHD predictor derived from discriminant function analysis using best predictors

36 Clinical Care zBehavior Rating Scales yParent Ratings generally show more impairment for child than do Teacher Ratings yMay want to use “blind” ratings from Teacher - where Teacher is unaware of use of medication yhelpful with treatment follow up studies

37 Clinical Care Issues zTreatment Issues yTreatment consistent with theoretical models for ADHD? yNIMH Treatment Guidelines xMedication effective, data indicated medication alone more effective than Medication & behavioral treatment Behavioral treatment alone Other modalities

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

39 Clinical Care Issues zNewer treatment modalities yNeurofeedback xIssues:standardization of treatment xLength of treatment xTreatment cessation: maintenance of gains

40 Clinical Care zTreatment considerations yStimulant medication is standard of care yNIMH revenue of ADHD studies suggested that xStimulant medication alone better than stimulant medication and behavioral therapy, behavioral therapy alone or placebo.

41 Clinical Care zTreatment considerations yMedications xmethylphenidate hydrochloride Ritalin Sustained Release Concerta xAmphetamines Adderall Dexedrine

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

43 Clinical Care zTreatment considerations yBehavioral Treatment xhome and classroom based intervention strategies xrequires cooperation of parents & teachers xeffective - but best when used with medication

44 Clinical Care zTreatment considerations yFamily Therapies xFamily system with behavioral interventions for child xDoes require intact family system

45 Clinical Care zTreatment considerations yStimulant medication is standard of care yNIMH revenue of ADHD studies suggested that xStimulant medication alone better than stimulant medication and behavioral therapy, behavioral therapy alone or placebo.

46 Clinical Care Issues zSummary: treatment goals and plans need to be consistent with theoretical models of ADHD zMedication: ritalin, adderall, others

47 Clinical Care Issues zSummary: treatment goals and plans need to be consistent with theoretical models of ADHD zMedication: ritalin, adderall, others

48 Continuous performance tests

49 zGrew out of need to provide for a measurement of attention and impulse control zWanted actual measurement not behavioral attributes

50 zAdvances in electronics provided format zHistorically, measures of sustained attention are intrical to the history of psychology zStudy 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,

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

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

53 Continuous Performance Tests zStill needed to inhibit action zAuthors found the task to adequately classify 84.2% to 89.5% of younger subjects who had brain damage zGreater classification was for AX-type

54 Continuous Performance Tests zSince 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 zRiccio 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 zResearch studies may use a cpt designed only for that study ylacking normative development yincreased difficulty with study replication zEasy to program (if you find programming easy) zMany variations of design

56 Continuous Performance Tests zCpt variations ystimulus presentation yinterval of stimulus ystimulus modality ydistraction modes yadaptive cpts ylength of task ytarget/nontarget ratio

57 Variations of CPTs zStimulus Presentation yX- type (easier task) yAX- type (more difficult task) yXX-type yNumeric (variation of X or AX type) xGDS uses numeric stimulus x1 - 9 type task (number 1 followed by number 9)

58 Variations of CPTs zInterstimulus Interval (ISI) variations yRosvold et al (1956) used 920 ms ysome have used from 50 to 1500 ms (Friedman, Vaughan & Erlenmeyer-Kimling (1981) y500 to 1500 ms (Schachar, Logan, Wachsmuth & Chajczyk, 1988) ysome tasks maintain consistent ISI yothers use variable ISI within task

59 Variations of CPTs zOther component related to ISI is that of stimulus onset asynchrony (SOA) zThis refers to the onset of the stimulus followed by the onset of the next stimulus zi.d., stimulus may “linger” longer allowing task recognition zsome cpts use variable SOA, others consistent SOA

60 Variations of CPTs zISI - SOA yincrease ISI decrease SOA xshorter SOA may increase “mis-hits” xshorter SOA may increase omissions yincrease ISI increase SOA xslower response times

61 Variations of CPTs zStimulus Modality (Visual/Auditory) yNon-alphanumeric xSquare within square (T.O.V.A.) xRabbit (in development) yAuditory stimulus presentation models xauditory X or AX types xauditory numeric xtones (T.O.V.A.-A.)

62 Variations of CPTs zDistraction ythese cpts use X or AX-type then add another dimension: interference or distraction ygoal is to increase level of difficulty ydistraction task varies by cpt xdegraded or blurred xvisual distractions common for visual X or AX cpts xauditory distractions

63 Variations of CPTs zAdaptive cpts yincrease level of difficulty as success of task accomplished and maintained

64 Variations of CPTs zLength of task yBremer (1989) reported “mini-cpt” x3 minute task x6 minute task available yT.O.V.A./T.O.V.A.-A xlongest x21.6 minutes

65 Variations of CPTs zTarget/nontarget ratio yrefers to presentation of targets to nontargets throughout task ysome use variable others consistent ysome use variable mixed with variable ISI

66 Comments zInfluences on cpt performance ydirections yexaminer presence yanxiety, depression and the rest of DSM-IV ydrugs and alcohol (including caffeine) yenvironmental distractions

67 The Big 4 z4 major cpts have emerged within the marketplace zall report normative and standardization zAlphabetical order: yConners’ CPT (“The cpt”??) yGDS yIVA yT.O.V.A./T.O.V.A.-A.

68 The Big 4 zConners’ CPT yAvailable from Multihealth Systems, Inc (MHS)* ywww.mhs.com y * may be available from other distributors such as PAR or WPS

69 The Big 4 zConners’CPT yType:not x yModality:Visual yStimulus display250 ms yISIvaried 1000 to 4000 ms (varied within block)

70 The Big 4 zConners’ CPT yTarget Letter yLength 14 minutes yNontargetsletters yDistractionnone yTarget ratio not varied

71 The Big 4 zConners’ CPT yBlock Timingyes yCustomized available yExaminer presence? yPractice trialsyes yStandardized instructionsyes

72 The Big 4 zConners’ CPT Scoring ycorrect hits yomission/commission errors yd-prime/beta yreaction time yreaction time standard deviation

73 The Big 4 zConners’CPT Scoring yslope of standard error yslope at ISI change yslope of standard error at ISI change yoverall performance index

74 The Big 4 zGDS: Gordon Diagnostic System yAvailable from: Gordon Systems, Inc. * ywww.gsi.com y * note: may be available from other distributors such as PAR, WPS

75 The Big 4 zGDS yTypeAX(numeric) yModalityVisual yStimulus display200 ms yISI1000/2000 ms (children adults/preschool)

76 The Big 4 zGDS yTarget number yLength9 minutes/6 for preschool yNontargets numbers yDistractionyes yTarget ratio not varied

77 The Big 4 zGDS yBlock Timing yes yCustomized available yExaminer presence yes yPractice trials yes

78 The Big 4 zGDS Scoring ycorrect hits yomission/commission errors yreaction time ytarget related error / random error

79 The Big 4 zIntermediate Visual and Auditory CPT (IVA) also known as Integrated Visual & Auditory CPT yAvailable from: BrainTrain * ywww.braintrain-online.com y * Note: May also be available from other distributors such as PAR, WPS

80 The Big 4 zIVA yType X yModality Visual & auditory in same task yStimulus Display 167 auditory/500 visual yISI 1500 ms

81 The Big 4 zIVA yTarget number yLength13 yNontargets numbers yDistraction no? yTarget ratio varied

82 The Big 4 zIVA yBlock Timing yes yCustomized no yExaminer presence yes yPractice trials yes

83 The Big 4 zIVA Scoring yresponse control quotient (auditory,visual, full) yattention quotient (auditory, visual, full) yauditory & visual prudence scores yvigilance yconsistency ystamina

84 The Big 4 zIVA Scoring yfocus yspeed ybalance ypersistence yfine motor/hyperactivity

85 The Big 4 zIVA Scoring ysensoriomotor yreadiness ycomprehension

86 The Big 4 zTest of Variables of Attention (T.O.V.A.) & Test of Variables of Attention-Auditory (T.O.V.A.-A.) yAvailable from: Universal Attention Disorders, Inc. ywww.tovatest.com y (800-PAY-ATTN) *Note: Also available from other distributors such as PAR, WPS

87 The Big 4 zT.O.V.A./T.O.V.A.-A. yType: X yModality: Visual/Auditory yStimulus display 100 ms yISI 2000 ms

88 The Big 4 zT.O.V.A./T.O.V.A.-A. yTarget position of square yLength 21.6 mins yNontargets position of square yDistraction no yTarget ratio varied

89 The Big 4 zT.O.V.A./T.O.V.A.-A. yBlock Timing yes yCustomized yes yExaminer presences yes yPractice trials yes

90 The Big 4 zT.O.V.A./T.O.V.A.-A. Scoring yomission/commission errors yresponse time yresponse time variability yd prime

91 The Big 4 zT.O.V.A./T.O.V.A.-A. Scoring ymultiple responses yanticipatory Responses yADHD scale ypost commission error response time

92 T.O.V.A. zNon-language based stimulus zX-type zSquare within square stimulus zSquare at top – target zSquare at bottom - nontarget

93 T.O.V.A. zT.O.V.A.-A. uses two tones: yMiddle c: non-target yG above middle C: target zConsistent with paradigm: top is the target

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

95 T.O.V.A. zSeparate standardization samples zOver 2500 subjects in T.O.V.A.-A. yAge 6 & above yAges zOver 2000 subjects in T.O.V.A. yAge 4-5: 11.3 minute version yOne quarter of target frequent/infrequent

96 T.O.V.A. zT.O.V.A. yOne year age increments ages 6 to 19 yData by gender yAges 20 & above: by decade yData by gender

97 T.O.V.A. zTwo conditions: target infrequent & target frequent z3.5:1 non-targets for every target (infrequent) z3.5:1 targets for every non-target: (frequent) zStimuli presented in a fixed random model

98 T.O.V.A. zQuarter 1 & 2: target infrequent ySubject who is inattentive likely to miss target yMeasure of attention yOmission errors likely zQuarter 3 & 4: target frequent ySubject who is impulsive likely to “mis-hit” yMeasure of impulse control yCommission errors likely

99 T.O.V.A. zScores presented by quarters, halves & total for each variable zScoring uses derived standard scores, 100 mean, 15 standard deviation zHigher scores reflect better performance, lower scores reflect poorer performance

100 T.O.V.A. zIn addition: yZ scores yPercentiles for RT & RTV zAnticipatory errors yResponses presented from 200 ms prior to stimulus onset to 200 ms after onset

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

102 T.O.V.A. zMultiple responses rare in standardization group yIncreased multiple responses decrease validity of subject performance zError Analysis: examiner is able to review all responses to all stimuli over duration of test

103 T.O.V.A. zADHD score yBased upon ROC discriminant function analysis yBest 3 predictors for placing subjects in ADHD prediction group yUses subject z scores

104 T.O.V.A. zADHD score yScores less than or equal to zero (0) indicate subject more likely to be placed in ADHD group yScores 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. zD Prime yMeasure of performance consistency over duration of task zBeta: not found to be significant between groups, thus is not reported

106 T.O.V.A. zConstruct validity Actual PredictedNormalADHD 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 20 th Annual Meeting of the National Academy of Neuropsychology. Orlando, FL.

107 T.O.V.A. zSensitive to malingering yIncreased errors across all 4 quarters, both halves and total score for omission & commission yDecreased response time yIncreased 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. zRelationship to IQ yGreenberg has reported need to adjust T.O.V.A. scores for IQ yHOWEVER – Research has indicated this to be a false assumption

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

110 T.O.V.A. zChae (1999) yFreedom from Distractibility factor not significantly correlated yProcessing Speed factor not significantly correlated

111 T.O.V.A. zOther studies have reported similar findings yAt best there is approximately a.50 correlation between FSIQ and T.O.V.A. scores yThird factor not significantly correlated with T.O.V.A. scores zIQ not factor in T.O.V.A. performance

112 T.O.V.A. zConstruct validity for T.O.V.A.-A yADHD (DSM-IV) to normal control children yDiagnosis 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 21 st Annual Meeting of the National Academy of Neuropsychology

113 T.O.V.A. zTemporal Stability of T.O.V.A. yInternal coefficients not appropriate for timed tasks yTemporal stability: reasonable time interval x90 minutes x1 week

114 T.O.V.A. z90 Minute Interval Scalecoefficient Omission0.80 Commission0.78 RT0.93 RTV0.77

115 T.O.V.A. z1 Week Interval yScaleCoefficient yOmission0.86 yCommission0.74 yRT0.79 yRTV0.87

116 T.O.V.A. zS em yScale90 Minute1 Week yOmission yCommission yRT yRTV Note: reflects T-scores

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

118 T.O.V.A. zForbes (1998) yACTers HyperOM -.37 COM -.30 yOppos OM -.38 COM -.25 yAttn OM -.25 COM -.16

119 T.O.V.A. zSelden, 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. zContinuous Performance Test (CPT) ymeasure of sustained attention & vigilance ymeasure of impulse control ylong, boring measures

121 T.O.V.A. zTest of Variables of Attention (Greenberg, 1992) yT.O.V.A. : non-language stimulus task ycomputer based yfixed two second interstimulus interval (ISI) y21.6 minute long task

122 T.O.V.A.

123 ztwo task paradigms: target infrequent & target frequent za constant 3.5:1 ratio yTarget Infrequent: 3.5: 1 non-targets to targets yTarget Frequent: 3.5:1 targets to non-targets

124 T.O.V.A. zInternally clocked zData summarized into quarters, halves and total score zQuarters 1 & 2 - target infrequent zQuarters 3 & 4 - target frequent zHalf 1 - target infrequent zHalf 2 - target frequent

125 T.O.V.A. zExtensive norm development: over 2300 subjects zScaled by age and gender zUses derived standard scores with mean of 100, standard deviation of 15 zz scores also provided

126 T.O.V.A. zT.O.V.A. Scales yOmission - measure of attention/inattention yCommission - measure of impulse control yResponse Time - in milliseconds yResponse Time Variability - measure of response consistency yd’ (d prime) - signal detection measure response consistency

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

128 T.O.V.A. zSemrud-Clikeman & Wical (1999) yevaluated attentional difficulties in children with complex partial seizures (CPS), CPS & ADHD, CPS without ADHD, and controls yused 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):

129 T.O.V.A. zSemrud-Clikeman & Wical (1999) Results: yFound poorest performance on the T.O.V.A. by the CPS/ADHD group. yDifficulty in attention was noted for children with epilepsy regardless of ADHD yWhen methylphenidate was administered to the ADHD groups - both improved on T.O.V.A. scores

130 T.O.V.A. zSemrud-Clikeman & Wical (1999) yConclusions xEpilepsy may dispose children to attention problems that can significantly impair with learning xImprovement, as measured by improved T.O.V.A. measures was found for both ADHD groups when methylphenidate was administered

131 T.O.V.A. zMautner, Thakkar, Kluwe & Leark (in press) yNF1, NF1 with ADHD, ADHD & controls yNF1 with ADHD & ADHD similar yover 15% of the NF1 participants displayed symptoms of ADHD yBoth 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 zTreatment considerations yMedications xmethylphenidate hydrochloride Ritalin Sustained Release Concerta xAmphetamines Adderall Dexedrine

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

134 Clinical Care zTreatment considerations yBehavioral Treatment xhome and classroom based intervention strategies xrequires cooperation of parents & teachers xeffective - but best when used with medication

135 Clinical Care zTreatment considerations yFamily Therapies xFamily system with behavioral interventions for child xDoes require intact family system

136 Clinical Care zTreatment considerations yStimulant medication is standard of care yNIMH revenue of ADHD studies suggested that xStimulant medication alone better than stimulant medication and behavioral therapy, behavioral therapy alone or placebo.

137 References


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