Lawrence Greenberg, MD
Professor Emeritus of Psychiatry
University of Minnesota
The following is a brief overview of our clinical work with children and adults with ADHD.
Before the first appointment
We obtain demographic information and presenting problems, inquire about any use of prescribed, over-the-counter, or other substances (including alcohol, caffeine, nicotine, and marijuana), and briefly describe our procedures and costs on the intake call.
If the identified patient is a child, we send them a behavior rating to have the teacher fill out, and request that relevant clinical and academic reports be sent to us. We also inquire how the parent will prepare the child for the first appointment, suggesting that they describe the T.O.V.A. as a computer game.
We ask that the intake of caffeine and nicotine on the morning of the appointment be limited, but do not require them to go "cold turkey" since abrupt withdrawal adversely affects T.O.V.A. performance.
If they are taking long acting substances that affect the brain, like antidepressants and anticonvulsants, they are advised to continue to take these medications as usual, and we take the probable effects into account when we interpret their T.O.V.A. performance.
If they are taking psychoactive medication for ADHD, we ask them to not take their morning dose but to bring it with them, and we arrange for an appointment early in the day.
Diagnostic appointment
After a brief introduction, we conduct a baseline (no psychostimulant) T.O.V.A. test unless we already have one that is less than four months old. If they are taking a psychostimulant for ADHD and, as instructed, have not taken their morning dose, we have them take their morning dose immediately after testing.
We then obtain the history, a brief mental status examination, a symptom behavior checklist, a side effects rating form (even if they are not being treated for ADHD), the parental behavior rating of the child, and a self-rating from teenagers and adults. A careful review of drug use is an important part of the history, especially with teenagers and adults.
If the initial clinical impression is that the patient does have an attention disorder, but the baseline visual T.O.V.A. is within normal limits, and/or there is a history suggesting that the patient has more difficulty with auditory than with visual information processing, we obtain an auditory T.O.V.A.-A. test on another morning.
If the patient is being treated for ADHD with a psychostimulant, we obtain a second T.O.V.A. 1.5 hours after they take their short-acting medication or 2.5-3.5 hours after they take their long acting medication.
We then review the data and our clinical impressions with the family/patient and give our recommendations that may include parental behavior management counseling, coaching (focused on acquiring good coping and organizational skills), counseling for the identified patient, consultation with the school/workplace, medication and non-medical treatments (such as biofeedback/neurofeedback), and further assessments, including psychological and educational testing, and treatment for other and/or co-morbid conditions such as sleep disorders, depression, and anxiety.
Based on their T.O.V.A. performance, we can often offer suggestions to help them deal with their ADHD. As an example, when the person has significant problems in the second half of the test, we suggest that they work in a less distracting environment with reduced off-task visual and auditory stimuli.
If the patient is an adult, we often do a second "interp" with them and their significant other(s) to discuss the findings and to suggest how they can help the situation.
Medication challenge test
If the patient is not already being treated for ADHD, and we have determined that the diagnosis is or includes ADHD, we recommend a challenge dose T.O.V.A. test on a subsequent day after discussing the potential side effects and benefits of medication.
Since low doses of psychostimulants improve attention while higher doses primarily affect behavior and may make attention worse, our challenge doses are small. Our experience with "low" challenge doses like 5 mg of methylphenidate surprises many clinicians. While 5 mg may be insufficient for a school aged child, it's often just right or even high for a teenager or an adult. We generally use even lower challenge doses (like 2.5 mg of methylphenidate) when tics, epilepsy, and brain damage are evident or suspected.
Many patients and/or their families are justifiably hesitant about the use of psychostimulants. In fact, until the use of a test like the T.O.V.A., ADHD was clearly overly diagnosed, and excessive medication was prescribed, leading to an unnecessarily high incidence of side effects and non-compliance.
Interpreting the medication challenge testing
Assuming that the baseline test performance is not within normal limits, the guidelines are:
If the on-medication T.O.V.A. test performance is within normal limits, we recommend a clinical trial for four weeks of the challenge dose and again review potential side effects.
If the on-medication T.O.V.A. test performance is better than baseline but not within normal limits, we recommend either a repeat challenge test or a four weeks clinical trial with a higher dose.
If the on-medication T.O.V.A. test performance is worse than baseline, we recommend either a repeat challenge test or a four weeks clinical trial of a lower dose or consider switching to another psychostimulant.
If some of the on-medication T.O.V.A. measured variables are better and some are worse than baseline, we recommend either a repeat challenge test or a four weeks clinical trial of a lower dose.
In all cases, if the patient complains of side effects, we lower the dose. By the way, one of the most common side effects is feeling jittery (like having too much coffee).
At the end of the diagnostic process, we obtain informed consent forms and send the clinical report to the family doctor and other involved professionals. We generally send the Classroom Intervention Report to the school, and review the Home Intervention Report with the family before giving them a copy of it.
Incidentally, we give our patients (or their parents) copies of our diagnostic consultations and clinical notes. However, we do not give them reports from other professionals nor the T.O.V.A.TM Interpretation Report (that is summarized in our reports).
After the clinical trial of medication
We obtain an interim history, a brief mental status examination, a symptom behavior checklist, a side effects rating form, a teacher's classroom behavior inventory, the parent's behavior rating of the child, a self-rating from teenagers and adults, and an on-medication T.O.V.A. or T.O.V.A.-A.
Treatment with medication
We generally initiate pharmacotherapy with inattention/distractibility as the targeted symptoms rather than overactivity, impulsivity/disinhibition, and problems in executive functioning in ADHD, because these symptoms often improve when inattention/ distractibility improves. If these symptoms remain significantly problematic, we generally prescribe a second medication (like Clonodine or Straterra) rather than increase the psychostimulant.
If there are "rebound" symptoms (irritability, increased activity level, etc.) when the medication "wears off" in the afternoon, or if the person would benefit from medication in the late afternoon and early evening because of homework, we prescribe a small dose of a short acting psychostimulant to be taken between 3-4 PM.
Of course, co-morbid conditions with symptoms (like depression) need to be factored in as well; thus, we re-assess all of the symptoms to determine what needs to be done.
If there are other symptoms that warrant treatment, we may initiate treatment or refer back to the prescribing clinician for treatment. If behavior remains a significant problem we may refer for a behavioral intervention or for an additional medication. If executive functioning problems are prominent, we may recommend treatment with an additional medication.
After reviewing the data and recommendations with the patient and/or family, we generally refer the patient back to the prescribing doctor or advanced practice nurse for monthly follow-up appointments.
Monitoring treatment
We see children and teenagers every six months and adults yearly with off- and on-medication T.O.V.A.s and clinical review to monitor their progress. These periodic reviews are necessary since the most effective doses tend to increase somewhat in children, level off and decrease in the early teen years, and, if the teenager doesn't "outgrow" the ADHD, the dose decreases in the late teens and early 20's and remains pretty much the same until the mid- to late 60s when it again drops.
When the attention disorder is the result of a traumatic brain injury (TBI), follow-up monitoring is especially important since some of persons with TBI recover and no longer need psychostimulants.
If you have questions or would like to consult about a particular T.O.V.A. report, please email (info@tovatest.com) or fax (1-800-452-6919 or 1-562-594-7770) the report to The TOVA Company and one of our board certified psychiatrists or neuropsychologists will contact you to consult with you about the results.