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[PPS]Theoretical Models of Explanation for ADHD

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  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University
  • Robert A. Leark, Ph.D., Assess & Tread ADD/ADHD Nov. 17, 2001, Trinity Western University

[PPS]Theoretical Models of Explanation for ADHD [PPS]Theoretical Models of Explanation for ADHD Presentation Transcript

  • 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
  • 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
  • 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
  • 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
  • Theoretical Models of Explanation
    • Recent Historical Models
      • Neuropsychologists typically conceptualize attention as:
        • selective processing
        • awareness of stimuli
  • 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
  • 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
  • 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.)
  • 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
  • Theoretical Models of Explanation
    • Historical
      • Mirsky (1987) proposed three factor model for attention
        • focusing of attention
        • sustaining of attention
        • shifting of attention
  • 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
  • Theoretical Models of Explanation
    • Historical
      • Luria’s 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Theoretical Models of Explanation
    • Barkley & Gordon (1994,1997,1998,2001)
      • basal ganglia
      • dopaminergic
      • disinhibition key factor to etiology
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Issues in Clinical Care
  • 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
  • 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
  • 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
  • Clinical Care
    • Diagnostic procedures
      • Behavioral rating scales
      • Measure of sustained attention & impulse control
      • Medication follow-up
  • Clinical Care
    • Behavior Rating Scales
      • Child-Behavior Checklist (CBCL)
        • Parent Rating
        • Teacher Rating
        • Item pure scales: no item overlap
  • Clinical Care
    • Behavior Rating Scales
      • BASC (Reynolds & Kamphaus)
        • Ages 2 - 18
        • Item pure scales: no item overlap
        • easy to administer
        • shorter: about 140 items
  • Clinical Care
    • Behavior Rating Scales
      • BASC (Reynolds & Kamphaus)
        • 2-6: parent/other ratings
        • 7-12: self rating
            • parent rating
            • teacher rating
            • student observation guide
  • Clinical Care
    • Behavior Rating Scales
      • BASC (Reynolds & Kamphaus)
        • 13-18: self
          • parent
          • teacher
        • student observation guide
  • Clinical Care
    • Behavior Rating Scales
      • BASC (Reynolds & Kamphaus)
        • New: ADHD predictor
        • derived from discriminant function analysis using best predictors
  • 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
  • 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
  • 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
  • Clinical Care Issues
    • Newer treatment modalities
      • Neurofeedback
        • Issues:standardization of treatment
        • Length of treatment
        • Treatment cessation: maintenance of gains
  • 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 .
  • Clinical Care
    • Treatment considerations
      • Medications
        • methylphenidate hydrochloride
          • Ritalin
          • Sustained Release
          • Concerta
        • Amphetamines
          • Adderall
          • Dexedrine
  • 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?
  • Clinical Care
    • Treatment considerations
      • Behavioral Treatment
        • home and classroom based intervention strategies
        • requires cooperation of parents & teachers
        • effective - but best when used with medication
  • Clinical Care
    • Treatment considerations
      • Family Therapies
        • Family system with behavioral interventions for child
        • Does require intact family system
  • 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 .
  • Clinical Care Issues
    • Summary: treatment goals and plans need to be consistent with theoretical models of ADHD
    • Medication: ritalin, adderall, others
  • Clinical Care Issues
    • Summary: treatment goals and plans need to be consistent with theoretical models of ADHD
    • Medication: ritalin, adderall, others
  • Continuous performance tests
    • Grew out of need to provide for a measurement of attention and impulse control
    • Wanted actual measurement not behavioral attributes
    • 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.
  • 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
  • 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
  • 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
  • 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
  • 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
  • Continuous Performance Tests
    • Cpt variations
      • stimulus presentation
      • interval of stimulus
      • stimulus modality
      • distraction modes
      • adaptive cpts
      • length of task
      • target/nontarget ratio
  • 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)
  • 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
  • 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
  • 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
  • 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.)
  • 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
  • Variations of CPTs
    • Adaptive cpts
      • increase level of difficulty as success of task accomplished and maintained
  • 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
  • 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
  • Comments
    • Influences on cpt performance
      • directions
      • examiner presence
      • anxiety, depression and the rest of DSM-IV
      • drugs and alcohol (including caffeine)
      • environmental distractions
  • 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.
  • 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
  • The Big 4
    • Conners’CPT
      • Type: not x
      • Modality: Visual
      • Stimulus display 250 ms
      • ISI varied 1000 to 4000 ms (varied within block)
  • The Big 4
    • Conners’ CPT
      • Target Letter
      • Length 14 minutes
      • Nontargets letters
      • Distraction none
      • Target ratio not varied
  • The Big 4
    • Conners’ CPT
      • Block Timing yes
      • Customized available
      • Examiner presence ?
      • Practice trials yes
      • Standardized instructions yes
  • The Big 4
    • Conners’ CPT Scoring
      • correct hits
      • omission/commission errors
      • d-prime/beta
      • reaction time
      • reaction time standard deviation
  • The Big 4
    • Conners’CPT Scoring
      • slope of standard error
      • slope at ISI change
      • slope of standard error at ISI change
      • overall performance index
  • 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
  • The Big 4
    • GDS
      • Type AX(numeric)
      • Modality Visual
      • Stimulus display 200 ms
      • ISI 1000/2000 ms
      • (children adults/preschool)
  • The Big 4
    • GDS
      • Target number
      • Length 9 minutes/6 for preschool
      • Nontargets numbers
      • Distraction yes
      • Target ratio not varied
  • The Big 4
    • GDS
      • Block Timing yes
      • Customized available
      • Examiner presence yes
      • Practice trials yes
  • The Big 4
    • GDS Scoring
      • correct hits
      • omission/commission errors
      • reaction time
      • target related error / random error
  • 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
  • The Big 4
    • IVA
      • Type X
      • Modality Visual & auditory in same task
      • Stimulus Display 167 auditory/500 visual
      • ISI 1500 ms
  • The Big 4
    • IVA
      • Target number
      • Length 13
      • Nontargets numbers
      • Distraction no?
      • Target ratio varied
  • The Big 4
    • IVA
      • Block Timing yes
      • Customized no
      • Examiner presence yes
      • Practice trials yes
  • The Big 4
    • IVA Scoring
      • response control quotient (auditory,visual, full)
      • attention quotient (auditory, visual, full)
      • auditory & visual prudence scores
      • vigilance
      • consistency
      • stamina
  • The Big 4
    • IVA Scoring
      • focus
      • speed
      • balance
      • persistence
      • fine motor/hyperactivity
  • The Big 4
    • IVA Scoring
      • sensoriomotor
      • readiness
      • comprehension
  • 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
  • The Big 4
    • T.O.V.A./T.O.V.A.-A.
      • Type: X
      • Modality: Visual/Auditory
      • Stimulus display 100 ms
      • ISI 2000 ms
  • 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
  • The Big 4
    • T.O.V.A./T.O.V.A.-A.
      • Block Timing yes
      • Customized yes
      • Examiner presences yes
      • Practice trials yes
  • The Big 4
    • T.O.V.A./T.O.V.A.-A. Scoring
      • omission/commission errors
      • response time
      • response time variability
      • d prime
  • The Big 4
    • T.O.V.A./T.O.V.A.-A. Scoring
      • multiple responses
      • anticipatory Responses
      • ADHD scale
      • post commission error response time
  • T.O.V.A.
    • Non-language based stimulus
    • X-type
    • Square within square stimulus
    • Square at top – target
    • Square at bottom - nontarget
  • 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
  • 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
  • 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
  • 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
  • T.O.V.A.
    • Two conditions: target infrequent & target frequent
    • 3.5:1 non-targets for every target (infrequent)
    • 3.5:1 targets for every non-target: (frequent)
    • Stimuli presented in a fixed random model
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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 20 th Annual Meeting of the National Academy of Neuropsychology. Orlando, FL.
  • 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
  • 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
  • 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
  • T.O.V.A.
    • Chae (1999)
      • Freedom from Distractibility factor not significantly correlated
      • Processing Speed factor not significantly correlated
  • 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
  • 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 21 st Annual Meeting of the National Academy of Neuropsychology
  • 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
  • T.O.V.A.
    • 90 Minute Interval
      • Scale coefficient
      • Omission 0.80
      • Commission 0.78
      • RT 0.93
      • RTV 0.77
  • T.O.V.A.
    • 1 Week Interval
      • Scale Coefficient
      • Omission 0.86
      • Commission 0.74
      • RT 0.79
      • RTV 0.87
  • T.O.V.A.
    • S em
      • 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
  • 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
  • T.O.V.A.
    • Forbes (1998)
      • ACTers Hyper OM -.37 COM -.30
      • Oppos OM -.38 COM -.25
      • Attn OM -.25 COM -.16
  • 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
  • T.O.V.A.
    • Continuous Performance Test (CPT)
      • measure of sustained attention & vigilance
      • measure of impulse control
      • long, boring measures
  • 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
  • T.O.V.A.
  • 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
  • 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
  • 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
  • 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
  • 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)
  • 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.
  • 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
  • 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
  • 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
  • Clinical Care
    • Treatment considerations
      • Medications
        • methylphenidate hydrochloride
          • Ritalin
          • Sustained Release
          • Concerta
        • Amphetamines
          • Adderall
          • Dexedrine
  • 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?
  • Clinical Care
    • Treatment considerations
      • Behavioral Treatment
        • home and classroom based intervention strategies
        • requires cooperation of parents & teachers
        • effective - but best when used with medication
  • Clinical Care
    • Treatment considerations
      • Family Therapies
        • Family system with behavioral interventions for child
        • Does require intact family system
  • 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 .
  • References