DSM-5 and the T.O.V.A.

The recently published DSM-5 contains changes of interest to T.O.V.A. users and has resulted in a fair amount of controversy. The diagnostic criteria of ADHD and Autism Spectrum Disorder (ASD) are changed, and the category of Neurocognitive Disorders (NCD), mild and major, is now included.

Thomas R. Insel, M.D., Director of the NIMH, announced that research based solely on the DSM-5 criteria will no longer be supported. His statement, “Patients with mental disorders deserve better,” was a call for better standards for understanding and treating people with mental health issues. Better standards include objective, accurate, and reliable measures like the T.O.V.A.

The primary changes to the ADHD criteria are that symptoms now need to be exhibited before the age of 12, adults need only 5 of 9 criteria, there is a scale for severity (mild, moderate and severe), and a person can be in partial remission. A key question is how will one determine the severity of a person’s ADHD? The T.O.V.A. Attention Performance Index (API) has the potential to help in that determination, and we would welcome your feedback and/or research proposals.

ASD will now include Aspergers and can be concurrently diagnosed with ADHD. This is not a surprise to many of us who have thought that attention issues often accompany ASD, previously known as Pervasive Developmental Disorder (PDD).

The new category of Neurocognitive Disorders (NCD) has essentially replaced Delirium, Dementia, Amnestic, and Other Cognitive Disorders in the DSM-IV. It can be mild or major with criteria set for each. Differentiating mild and major may be helpful in getting care for patients. Mild NCD resulting from a Traumatic Brain Injury will likely open the door for new testing, assessment, and treatment of mild TBI, and our hope is that recognition of short and long term attention deficits as a result of head injuries will become the standard rather than the exception.

One of the problems with the DSM-5 is that knowing that a person meets the diagnostic criteria for ADHD, ASD, or NCD doesn’t help us understand the causes of the symptoms. We can know that a person’s symptoms meet the criteria for ADHD, Inattentive Type, but we don’t know what is causing the difficulties. Is it a short attention span? Is information being processed inconsistently or too slowly? And/or are impulses inadequately controlled?

Our goal is to help you get a deeper and clearer understanding of a person’s auditory and visual attention and information processing, and to answer as many questions about the what and the why of the symptoms. The T.O.V.A. provides the objective information that you and your patients need.

Case Illustration

A 5.4-years-old boy was referred because of persistent impulsivity, negativism, and irritability at home and in preschool. Reports and behavior ratings by his parents and teacher were indicative of a behavior disorder, and the diagnosis being considered was Oppositional Defiance Disorder (ODD). There was no history of Traumatic Brain Injury, and no one mentioned an attention problem in any of his reports. His pediatrician thought a T.O.V.A would be helpful in understanding his behavior. His scores on the Visual T.O.V.A. are as follows:

Visual T.O.V.A. 
(Standard Scores)
  Half 1 Half 2 Total
Variability                                105 88 91
Response Time 115 109 110
Commissions 100 86 94
Omissions 110 76* 85b
* = significantly deviant from the norm, b = borderline

The 10.8 minutes T.O.V.A. test, automatically selected because the boy was 5.4 years old, consisted of Half 1 (infrequent targets) and Half 2 (frequent targets).

The youngster did well in Half 1, but Variability dropped 17 points and Commission Errors dropped 14 points in Half 2. (A drop or increase of half a standard deviation [7.5 points] or more is a significant change). Omission Errors became significantly deviant from the norm in Half 2. Like most people, he did slow down after making a Commission Error (Post-Commission Response Times were slower than Response Times). Had he been oppositional defiant, he might have sped up after making a Commission Error.

The Notes page reported that there were five episodes (one with 13 Omissions) where three or more Omission Errors occurred in a row in Half 2. This is unusual, and one needs to identify the reason for this because of the possibility of petit mal seizures or narcolepsy.

In Half 2 the youngster complained about taking the test, looked about the room frequently, and at one point laid the microswitch on the table. The test administrator recorded these observations on the T.O.V.A. Observation Form, and noted that the boy seemed more frustrated than angry and “gave up” for a while. Interestingly, after a pause he began again. This is crucial information for understanding the boy’s attitude and behavior.

Overall, based on his T.O.V.A. performance, his information processing was significantly deviant from the norm and compatible with an attention disorder. The data indicated that he became fatigued after 5.5 minutes and/or over-simulated in Half 2, and his attention processing suffered. The clinician needed to decide whether the boy’s behavior problems were due to an attention problem, ODD, or a combination of the two. In light of the information received from the T.O.V.A. Report and the T.O.V.A. Observation Form, the clinician initiated a discussion with the parents that led to a new way of looking at their son. Subsequently, the teacher confirmed that the boy’s behavior became symptomatic in the classroom with longer or more stimulating tasks. Based on all of this information, the clinician made the diagnosis of ADHD. Medication and counseling was initiated for the boy, and his parents were referred to a support group for families with ADHD. The clinician plans to use follow-up behavior ratings and a new T. O.V.A. to track the youngster’s response to treatment, providing the better care that Dr. Insel states is needed for our patients.

This case illustrates the need for an objective measure like the T.O.V.A. in addition to the subjective criteria of the DSM-5. A more complete picture creates the opportunity for more successful outcomes.