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In This Issue

• What's Happening in the Brain During the T.O.V.A.?
• Case of the Month
• Frequently Asked Questions
• Bulk Discounts
• Meet the T.O.V.A. Team!

What's Happening in the Brain During the T.O.V.A.?

Occasionally, T.O.V.A. users ask us what we know about brainwave activity during administration of the T.O.V.A. Here is some information that we hope will "evoke" some interest!

As you know, the T.O.V.A. presents target and non-target stimuli in a pseudo-random sequence, with infrequent target stimuli during the first half and frequent target stimuli during the second half. The infrequent target condition, in which the target stimulus is presented at a ratio of 3.5 targets to one non-target, can be considered an example of a classic "evoked potential" brainwave response paradigm first reported in the 1960s, the "P300 task".

The P300 evoked response was first described in a study by Sutton, Braren, Zubin, and John (1965) in an article published in the journal Science. The term "P300" refers to a positive (in terms of voltage) brainwave response that occurs about 300 milliseconds after detection of an unpredictable "oddball" stimulus presented as part of a series of target and nontarget stimuli.

The P300 appears to be associated with the "aha!" or "that's it!" cognitive response that occurs with perception of the unpredictable, target or "oddball" stimulus. As such, it is believed to originate at least partially in areas of the limbic system (the emotional centers of the brain), but also appears to emanate from a number of other regions, including the posterior and superior parietal cortices, cingulate gyrus, and temporoparietal cortex.

The P300 is an interesting and widely-studied brain response. It has been shown to be slower and weaker in individuals suffering from a range of brain-based disorders, especially schizophrenia. The P300 response is also smaller in amplitude in individuals who suffer from alcoholism and other addiction problems and has been considered a possible marker for addiction-related disorders. The P300 response may also be modified in response to traumatic brain injury.

Because it is obligatory (that is, cannot be deliberately manipulated), the P300 response has even been used in lie detection! In the "guilty knowledge" paradigm, the subject is exposed to a sequence of familiar and unfamiliar stimuli, with some of the stimuli being objects that would only be familiar to the perpetrator of a specific crime (e.g, photos of the crime scene, or a weapon used in commission of the crime). If the "oddball" P300 response is not produced in response to these details, it can be presumed that the subject is familiar with these stimuli and thus has "guilty knowledge" associated with particulars of the crime.

So what is going on in the brain during the T.O.V.A.? Well, for at least half of the task, the brain is certainly producing a nice P300 response whenever it perceives the target stimulus--again, the first half of the T.O.V.A. is a classic P300 paradigm.

While it has not yet been studied, it is likely that something changes during the second half of the T.O.V.A. As the brain begins to understand that the target stimulus is no longer the "oddball" (since the target to nontarget ratio becomes 3.5 to one) it is possible that the P300 response may shift to presentation of the nontarget stimulus. We really don't know if or when this occurs, and it remains an intriguing question.

We also don't know whether different groups (for example, persons diagnosed with ADHD) might demonstrate a different rate of "stimulus crossover" compared to undiagnosed individuals. This would be a fascinating subject of further inquiry, and one that we would be quite interested in pursuing with a research-minded T.O.V.A. user. If you think you might be interested, drop us a line at research@thetovacompany.com with your ideas!

To learn more about the P300 evoked response, check out the Wikipedia article at http://en.wikipedia.org/wiki/P300_(Neuroscience) (which served as the source for some of the material in this article).

References:

Sutton, S., Braren, M., Zubin, J., & John, E. R. (1965). Evoked-Potential Correlates of Stimulus Uncertainty. Science, 150(3700), 1187-1188.

T.O.V.A. Case of the Month: Assessing the Effectiveness of Treatment

This case illustrates the importance of using the T.O.V.A. when assessing the effectiveness of treatment of an attention disorder. Reliance solely on subjective reports and equally subjective behavior ratings too often results in prescribing excessive medication, less-than-optimal clinical results, increased incidence of side effects, and noncompliance.

For several weeks after this 24-year-old female was in an auto accident, reportedly experiencing only minor head injuries, she complained of being easily distracted, disorganized, "fretful", and had difficulty completing multi-step tasks. Prior to the accident she had completed college with honors and was successfully working as an accountant. The history, the behavior and symptom ratings, and the mental status examination, and the T.O.V.A. led to the diagnosis of ADHD caused by a traumatic brain injury (TBI). In addition to a neuropsychological assessment, it was decided to evaluate whether medication would be helpful. Let's look at her T.O.V.A. test results.

Standard Scores for First T.O.V.A. Test (No medication)

* significantly deviant (standard score <80)

ADHD Score: -4.62

Her first T.O.V.A. performance and the ADHD Score (-4.62) were significantly deviant from the norm and compatible with an attention disorder.

Although Variability significantly improved from quarter 1 to quarter 2, it again became deviant in the second half. The deviant Variability in quarter 1 could represent some initial test anxiety. However, she clearly had a great deal of difficulty maintaining consistent response times in the more pressured, response driven second half. Therapeutically, we could help her learn how to reduce the stress of high demanding tasks in her everyday life.

Response Time slowed in each successive quarter, becoming significantly deviant in quarter 4. This may simply represent gradually "running out of steam" over time, especially after 15 minutes. If she was slowing down (consciously or not) to minimize commission errors, she was successful.

Somewhat inattentive in quarters 1,2, and 4, her omissions were significantly deviant in quarter 3. She may have been "shocked" when the test condition suddenly changed. In this case, we might want to help her minimize abrupt changes in her everyday life.

Standard Scores for the Second T.O.V.A. Test (1.5 hours after taking a challenge dose of 5 mg of methylphenidate)

* significantly deviant
b borderline (standard score 80-85)

ADHD Score: +0.49

There is significant improvement with 5 mg of methylphenidate.

Response Time Variability improves and normalizes in all quarters although it is only borderline in quarters 3 and 4.

Response Time improves dramatically and normalizes.

While she makes more commission errors in quarters 1 and 2, perhaps because she is responding much faster, they remain within normal range.

Omissions and ADHD Score are now within the normal range.

While it would have been reasonable to do a clinical trial of 5 mg of methylphenidate, she experienced feeling "nervous", like having too much coffee, a common side effect of excessive psychostimulant medication. Thus, a lower challenge dose (2.5 mg) was then tested.

Standard Scores for the Third T.O.V.A. Test (1.5 hours after taking a challenge dose of 2.5 mg of methylphenidate)

ADHD Score: +2.90

With 2.5 mg, all of the variables and the ADHD Score are within or above normal limits.

A clinical trial of 2.5 mg of methylphenidate twice a day was conducted for four weeks. History, behavior and symptom ratings, and the T.O.V.A. all indicated continued response to the medication. The plans are to continue the medication and retest every 6 months since there is a possibility of recovery.

Frequently Asked Questions

"Why do I have to pay for each T.O.V.A. Report? Other CPTs don't charge for them."

We charge for each report in order to provide you with:

• free technical support by on-staff engineers
• free clinical support by experienced clinicians (both PhD and MD)
• free software upgrades, with exciting new features soon to include:
  • more norms
  • drastically improved reports
  • new, more accurate outcome measures
  • a "fake bad" measure
  • support for new platforms, including Windows Vista and Mac OS X
• low-cost workshops and other educational activities
• assurance that your CPT remains state-of-the-art

With the income we also:

• grant free T.O.V.A. Tests for attention research in ADD, dementia, TBI, etc.
• give almost-free tests to schools and clinical training programs
• grant free tests and software worldwide to clinical services in need

This underscores the fact that we're a service-dedicated company: service to you and service to the community.

Discounts for bulk T.O.V.A. Interpretation Credits

The TOVA Company is pleased to provide discounts on bulk purchases of Interpretation Credits.

Single-Order Discounts: Single-order discounts apply to any T.O.V.A. provider ordering Interpretation Credits for a single T.O.V.A. Scorebox. No other discounts may be applied.

Monthly-Order Discounts : Monthly-order discounts apply to any system (e.g.: agency, health insurance system, associated clinics, etc.) with one billing address that guarantees a monthly order for 12 months of Interpretation Credits. Note: Individual practitioners may not join together to qualify.

For additional information on monthly orders, please contact The TOVA Company.

Meet the T.O.V.A. Team!

Meet Carol Kindschi, RN, MSN and CEO of The TOVA Company. Her training and work as a nurse in child and adolescent psychiatry led to her involvement with attention and its impact on lives. She lives predominantly in Mexico with her husband, Larry Greenberg, author of the T.O.V.A.

Becoming CEO of The TOVA Company was not on my "to do" list. And yet as my path meandered, I arrived to exactly the right place.

As a staff nurse in adolescent psychiatry in 1974, I was part of a team developing a hyperactivity behavior rating for inpatient children and adolescents when conventional wisdom was "No hyperactivity = no problem."

A few years later I was coordinating a university-based medication clinic for hyperactive children. I now shudder as I recall the standard methylphenidate dose - one mg/kg body weight, no matter what - and then waiting for the side effects to appear and the phone calls from worried parents about sleep disturbance and appetite loss in their children.

Thankfully, the research going on in the same clinic using the precursor to the T.O.V.A. began to support lower doses with no loss of benefit. My graduate school research, so many years ago, combined the more subjective behavior ratings of the day with beginning normative work on what now is the T.O.V.A: a blending of the subjective world with the objective world - the next frontier.

This day job was in sync with my interest in depth psychology that led me to pediatric nursing in the first place. At that time, I wanted to work with children because, in my experience, they only let you near them if you paid attention to their entire being, and not just their lab values and test results. Now, thankfully, adults have learned from children, and a more holistic approach is accessible in a wider range of situations. And since I view the T.O.V.A. as an objective measure that allows for a holistic response, I'm in.

Looking at the reading material on my bedside table, there is a wild mixture of business reviews, cross-cultural symbolism, Jungian and Sandplay therapy, dream journals, solar home designs, finances, mystery novels, neuropsychology, shamanic healing, and articles on composting toilets. A blending of the subjective with the objective world - the next frontier.

In addition to playing an active role in The TOVA Company, as Larry mentioned last month, we and a small group of American and Mexican healers are creating a sustainable community in rural Mexico, near Guadalajara. This is an outward expression of our ongoing commitment to supporting the world for future generations. To this end, the use of the T.O.V.A. worldwide to improve the life of others is right on target.