Seeking an Objective Test for Attention Disorder
WALNUT CREEK, Calif. — I’m sitting in front of a gray plastic console that resembles an airplane cockpit. Each time I move, a small reflector on a makeshift tiara resting on my forehead alerts an infrared tracking device pointing down at me from above a computer monitor. Watching the screen, I’m supposed to click a mouse each time I see a star with five or eight points, but not for stars with only four points.
It’s a truly simple task, and I’m a college-educated professional.
So why do I keep getting it wrong?
Halfway into the 20-minute session, I find myself clicking at a lot of four-point stars, while sighing and cursing with each new mistake and stamping my feet, sending further unflattering information to the contraption via tracking straps taped to my legs.
Dr. Martin H. Teicher, the Harvard psychiatrist who invented the test, has an explanation for my predicament.
“You have some objective evidence for an impairment in attention,” he said — in other words, a “very subtle” case of attention deficit hyperactivity disorder. (Indeed, I had already received a diagnosis three years earlier.) Not only did I click too many times when I shouldn’t have, and occasionally vice versa, but subtle shifts in my head movements, tracked by the device’s motion detector, suggested that I tended to shift attention states, from on-task to impulsive to distracted and back.
Dr. Teicher’s invention, the Quotient A.D.H.D. System, is only one of several continuing efforts to find a biomarker — i.e., distinctive biological evidence — for this elusive disorder. Most mainstream researchers consider A.D.H.D. to be an authentic neurological deficit that, left untreated, can ruin not only school report cards, but lives. Nonetheless the quest for objective evidence has gained new urgency in recent years.
Many critics say the disorder is being rampantly overdiagnosed by pill-pushing doctors in league with the drug industry, abetted by a culture of overanxious parents and compliant educators.
These critics say that the standard treatment — stimulant medications like Ritalin and Adderall — carries a high risk for side effects and abuse in children whose attention problems might have no biological cause.
Yet despite the perils of faulty diagnosis, the most common way of detecting the disorder has nothing directly to do with biology. Instead, patients — along with their parents and teachers, in the case of children — are asked to respond to a checklist of questions about symptoms that most mortals suffer at one time or another. Do you (or your child) often make careless mistakes? Do you often seem not to listen when spoken to directly? Do you often not follow through on instructions?
This method, similar to the way doctors diagnose most mental illnesses, is so subjective that the answers, and the diagnosis, may depend on how distressed a patient, a parent or a teacher is feeling on a given day. Moreover, parents and teachers, and indeed mothers and fathers, can disagree, obliging a doctor to choose whom to believe. All this helps explain why an objective test has become “the holy grail” for many researchers, said Stephen Hinshaw, chairman of the psychology department at the University of California, Berkeley. Still, he and other experts are not convinced that any one test developed so far has proved better than the prevailing checklist method.
Many psychologists who offer comprehensive testing of children with undiagnosed learning problems include some variation of the Continuous Performance Test, a computerized assessment that measures distractibility; it is similar to Dr. Teicher’s invention, but without the motion detector.
In Southern California, meanwhile, Dr. Daniel G. Amen has built a business empire on his assertion that he can detect A.D.H.D. with a brain scan using a technology called Spect, for single photon emission computed tomography — a claim still unestablished in peer-reviewed reports of clinical trials.
In contrast, Dr. Teicher has reported on trials of his test’s efficacy in the Journal of the American Academy of Child and Adolescent Psychiatry. The Food and Drug Administration approved sales of the device in 2002, and several insurers, including Aetna and Blue Cross, now cover the test, according to Carrie Mulherin, a vice president at BioBehavioral Diagnostics, a startup company in Westford, Mass., that is marketing Dr. Teicher’s system (and paying him royalties; the list price is $19,500).
To date, more than 70 clinicians in 21 states have bought or leased a Quotient system, Ms. Mulherin said.
Dr. M. Randall Bloch, the Walnut Creek psychiatrist who was demonstrating the program for me recently, has been leasing it since last September, while considering a purchase. “I think it’s really cool,” he said. “It would be great to have more objectivity.” In addition to his lease payments, Dr. Bloch pays BioBehavioral Diagnostics $55 for each patient taking the test, while charging insurance companies as much as $200. While he says he wouldn’t diagnose the disorder on the basis of test scores alone, he has found the system a useful way to seal the diagnosis with patients or their parents who may be reluctant to try medication.
The Quotient system has also helped Dr. Bloch discourage patients who have claimed to have attention problems but who, he suspects, were merely interested in taking stimulants for fun, or in hopes of more productivity.
“You can tell if they’re trying to game the test,” he told me, pointing to a colored graph on my own assessment denoting attention states. Green marks attentive, yellow is impulsive, red is distracted and blue is “disengaged.” A lot of blue might lead to the suspicion that someone is failing on purpose.
While I switched among green, red and yellow, I didn’t have any blue on my graph.
“You were working hard,” Dr. Bloch said, approvingly.
“It’s how I cope,” I muttered.
Dr. Teicher said the Quotient system offered an efficient way to figure out the most helpful kind and dose of medication to treat attention problems.
“The stimulants work very quickly,” he explained. “So once we’ve tested a child, we could give him a dose, wait 90 minutes, and if he’s a responder, his performance will improve enormously. If not, we can bring him back the following week and try a different medication. This is a process that normally takes months or years.”
The key to his system, he said, is what he suspects will eventually be confirmed as a valid biological marker for A.D.H.D.: an unstable control of head movements and posture, particularly while paying attention to a boring task. Last fall the National Institutes of Health awarded Dr. Teicher a $1 million grant from the federal stimulus package to delve further into the quest for a definitive test or biomarker for the disorder. He plans to focus his research on three detective strategies: his Quotient system, magnetic resonance imaging to compare blood flows in different brain regions, and the ActiGraph, an activity monitor widely used by medical researchers.
James M. Swanson, a developmental psychologist and attention researcher at the University of California, Irvine, praised Dr. Teicher’s research, echoing his concerns about the need for a more objective test to detect the disorder. But he questioned whether the Quotient system produces more reliable diagnoses than a doctor’s dogged questioning of a child’s parents and teachers, and also whether it is an appropriate way to figure out the right dose of medication.
“It’s essentially a dull, boring task,” he said of the Quotient system, “so do you want to medicate your child to pay attention to dull, boring tasks?”
As I left Dr. Bloch’s office with my printed-out assessment, I pondered some questions of my own. How much of my supposed impairment is rooted in my brain, and how much in a culture that daily trains me to yank my focus between e-mail and cellphone calls? Do I need Ritalin or a meditation retreat — or just more interesting work, or maybe more peaceful children?
I could use an objective test for this one. Is anyone working on it?
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