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The T.O.V.A. and Adult ADHD

"With the increased public awareness about ADHD in adults, clinicians should prepare themselves to properly recognize, diagnose, and manage these adults as they become an increasing percentage of the clinically referred outpatient population." (Barkley, Murphy, & Fischer, 2007, p. 25)

Recognition of the impact of ADHD in adults has grown steadily in recent years. Current research suggests that about 5% of adults suffer from clinically significant impairments in attention and concentration skills, with even higher rates in persons who have a family member who has been diagnosed with ADHD (Barkley, Murphy & Fischer, 2007).

Every day, clinicians are hearing patients report problems with attention, concentration, and general cognitive efficiency, but there's a problem: The diagnostic criteria presented in DSM-IV-TR were not developed for use with adults, making the diagnosis difficult. Since the symptoms of ADHD were developed for use with children, many of the symptoms that define the disorder simply aren't applicable to adults (Barkley, Murphy & Fischer, 2008). Further, the requirement that the symptoms be present before the age of 7 makes it technically impossible to diagnose ADHD in an adult who did not manifest significant impairment in childhood!

So how can you do good diagnostic work and treat adults with ADHD? Best practices require consideration of new behavioral diagnostic criteria developed specifically for use with adults (Barkley, Murphy & Fischer, 2007), age-adjusted symptom thresholds, and the willingness to go beyond simple interview and self-report measures to incorporate convergent methods in diagnosis and treatment management. Your approach should include a detailed history of attention problems, collateral evidence of impairment in occupational, academic, or social functioning, and use of objective measures known to be sensitive to attention impairment (Mapou, 2008).

Around the world, clinicians rely on the T.O.V.A. to confirm the clinical diagnosis of reported ADHD symptoms and to obtain critical information about their patients' sustained attention, self-control, and adaptability. These aspects of executive functioning are essential for effective goal-directed behavior and are commonly impaired in persons suffering from ADHD and other conditions (e.g., traumatic brain injury) in which attention is affected.

While interviews, behavioral observations, and questionnaires provide useful information about attention, the T.O.V.A. gives you objective information that is significantly more precise than that which is obtained with self-report or observational methods. It provides "an important source of unique, objective, and valid information" (Forbes, 1998, p. 474) about these essential aspects of cognitive functioning. In addition, the T.O.V.A. is extraordinarily sensitive to treatment effects (both medical and behavioral; see Jensen & Kennedy, 2004) and can be used to document treatment efficacy or even inform clinical decision making about treatments.

Another consideration in working with adults reporting symptoms of ADHD is the heightened risk of symptom exaggeration or frank malingering (Sullivan, May & Galbally, 2007). Did you know that the T.O.V.A. can help you identify cases where symptom exaggeration or malingering is present? It's true! The T.O.V.A. Symptom Exaggeration Index is a crucial tool to help ensure that patients who need treatment get it, and help make sure that persons seeking medication for other purposes don't get it. Check out the June 2009 issue of The T.O.V.A. Times for more information.

Learn more about SEI at one of our T.O.V.A. workshops.

References

Barkley, R. A., Fischer, M., Smallish, L., & Fletcher, K. (2002). The persistence of attention-deficit/hyperactivity disorder into young adulthood as a function of reporting source and definition of disorder. Journal of Abnormal Psychology, 111(2), 279-289.

Forbes, G. B. (1998). Clinical utility of the test of variables of attention (TOVA) in the diagnosis of attention-deficit/hyperactivity disorder. Journal of Clinical Psychology, 54(4), 461-476.

Jensen, P. S., & Kenny, D. T. (2004). The effects of yoga on the attention and behavior of boys with Attention-Deficit/hyperactivity Disorder (ADHD). J Atten Disord, 7(4), 205-216.

Mapou, R. (2008). Adult Learning Disabilities and ADHD: Research Informed Assessment. Oxford.

Sullivan, B.K, May, K., & Galbally, L. (2007). Symptom Exaggeration by College Adults in ADHD and Learning Disorders Assessments. The Clinical Neuropsychologist. T.O.V.A. User Profile: Robb Mapou, PhD, LP, ABPP-CN

Featured T.O.V.A. User

We were recently able to visit with Dr. Robb Mapau, nationally known expert on adult ADHD and learning disabilities and longtime T.O.V.A. user.

What sort of practice do you have?

The focus of our practice group is assessment of LD and ADHD across the life span. I work with adolescents and adults, age 13 and up, although the bulk of my practice is with high school and college students.

How long have you been using the T.O.V.A.?

I began using the T.O.V.A. in 1993, when I started working with Bill Stixrud, who runs our practice. In fact, Bill was one of the first to use the T.O.V.A. He trained in Minnesota and actually knew Larry Greenberg [University of Minnesota Professor Emeritus of Child and Adolescent Psychiatry, and author of the T.O.V.A].

How do you use the T.O.V.A. in your work?

I use it routinely - with practically every patient. We do comprehensive assessments, so we're casting a wide net and looking at all different diagnostic possibilities.

Of course, we asked Dr. Mapou for his thoughts about the T.O.V.A., and here are some of his comments:

If you look at the vigilance literature in adults, you'll see that adults take a while to develop a performance decrement. The problem that I see with [other CPT measures] is that they are relatively short; the T.O.V.A. gives the patient a substantial amount of time to demonstrate a performance deficit, which may not happen on shorter tasks.

The T.O.V.A. can tell you if the patient has an attention problem. It can tell you about how the patient's attention problem looks [based on the T.O.V.A. profile] and can add a lot of interesting information about the patient that you can use, but it alone does not make a diagnosis.

The other thing that I like is the potential of the T.O.V.A. to pick up on poor effort. There are several studies that show people trying to fake ADHD perform much worse than people who actually have ADHD, and the T.O.V.A. is another tool to help identify that. As a field, we're moving toward more embedded measures of effort, and this new feature of the T.O.V.A. is really helpful. I used to believe standard scores that were < 40 were legitimate, but based on the research, I am now far more likely to question these.

What inspired you to write a book about adult ADHD and LD?

The book came about because of my interest in teaching clinicians how to do this work; that is, how to assess ADHD and LD in adults based on research. It got its start with my workshops.

Are you working on any new projects?

Yes. I now plan to write a book especially for consumers about the benefits of having a good assessment. The tentative title is "Adult LD Success Stories." It will give the basics of what learning disabilities are and how they are assessed. It will include a number of stories of people that I've seen - from college students to practicing physicians - and show how assessments have helped them.

Dr. Mapou is an ABPP board-certified clinical neuropsychologist, past president and vice president of the American Academy of Clinical Neuropsychology and holds faculty appointments in the Department of Neurology at Georgetown University School of Medicine and the Departments of Psychiatry and Neurology at the Uniformed Services University of the Health Sciences. He has published and presented widely on topics of adult learning disabilities and ADHD, neuropsychological assessment, cognitive and behavioral effects of traumatic brain injury, the neurobehavioral effects of HIV disease, and other neuropsychological issues. Dr. Mapou has served on the editorial boards of Neuropsychology, the Journal of the International Neuropsychological Society, and the Journal of Head Trauma Rehabilitation. His 2009 book, Adult Learning Disabilities and ADHD: Research Informed Assessment, published by Oxford University Press, was the first to summarize research on learni ng disabilities and ADHD in adults and use it to guide neuropsychological assessment.

Look for more featured T.O.V.A. providers in upcoming newsletters.