Poster Presentation
October 27-29, 2011
Savannah, Georgia (CS-29)
Utility of Objective Measures of Activity and Analysis of Attention State
in the Assessment of Therapeutic Response to Medications in Patients
with ADHD: Community Care Perspective
Henry Hasson, MD.
Albert Einstein College of Medicine of Yeshiva University, Brooklyn, NY
Abstract
Objective: The NIMH Multimodal Treatment of ADHD Study (MTA) of 579 children with ADHD
showed routine community care rendered only about 25% of these patients symptom free. This
study is to determine the utility of objective measures of hyperactivity, impulsivity and inattention
in a community care setting to achieve optimal therapeutic response to ADHD medications rapidly.
Methods: Patients age 6 to 12 years old were evaluated by a board certified child neurologist. Patients
with an established diagnosis of ADHD and new patients suspected of having ADHD were tested
using the Quotient® ADHD System, a 15-minute computer-based test that combines 6 measures of
micro-motion with 13 results from an attention task. Patients meeting the DSM-IV criteria for ADHD
were treated and re-assessed in 1-2 weeks.
Results: Thirty-five children with at least 2 Quotient ADHD Tests were included in this series, including
8 children who were on medication for Test #1. 16 (45.7%) achieved normalized motion and attention
metrics at the time of the second assessment; 6 (17.1%) achieved normalized motion control, but
excessive inattention remained; 4 (11.4%) achieved normalized attention, but excessive hyperactivity
remained; and 9 (25.7%) had excessive hyperactivity and inattention. 5 of the 15 patients with
normalized motion and attention scores at the time of the second test, were previously treated, but
not well controlled at baseline.
Conclusions: It is feasible and practical to implement an objective measurement of hyperactivity
and analysis of shifts in attention state using the Quotient ADHD Test in a community care setting.
Follow-up studies are needed to determine the time to optimal medication management compared
to rating scales, and the impact on compliance, adherence and patient satisfaction.
Methods
Quotient System: Kiosk
ADHD Assessment Protocol
• History, physical exam, clinical interview of patient, parent interview
• Objective, quantitative assessment with the Quotient System
Child Test: 1 target, 1 non-target
15 min. age 6-12, 20 min. ages 13-14
Older Adolescent/Adult Test:
3 targets, 1 non-target, 20 min.
Motion Tracking System
Quotient System: Portable
Reflector
Motion
Tracking
System
The Quotient® ADHD Test Report
Motion Analysis
Attention Analysis
Attention State Analysis
Scaled Scores & Global Score
Results
Total
Boys
Girls
Number
35
24
11
Mean Age at Test 1
9.1
9.2
8.9
6.0-12.8
6.2-12.8
6.0-12.6
Range
Baseline Category
Avg. time
between
tests
Medicated
Motion &
Attention
Dyscontrol
Motion
Dyscontrol
Only
Attention
Dyscontrol
Only
Motion &
Attention in
ref. range
Test 1
8
20
4
2
1
Motion and Attention
4
20
Motion Only
1
Attention Only
0
Normalized
3
Test 2
13.1 days
4
2
1
8
20
4
2
1
Motion and Attention
3
6
0
0
0
Motion Only
0
4
1
0
0
Attention Only
0
5
3
0
0
Normalized
5
5
0
2
1
2
13
0
0
0
Motion and Attention
0
4
0
0
0
Motion Only
0
1
0
0
0
Attention Only
0
1
0
0
0
Normalized
2
7
0
0
0
Test 3
28.8 days
Patients were classified into sub-groups according to the Scaled Scores for each test in order to compare baseline results with subsequent
results. A Scaled Score >5 was defined as dyscontrol and <5 was defined as normalized. Examples:
Test 1:
■■ Medicated (N=8): 4 children had motion and attention dyscontrol, 1 had motion dyscontrol but normal attention, 3 were normalized.
■■ Not Medicated: 20 children had attention and motion dyscontrol, 4 had motion dyscontrol only, 2 had attention dyscontrol only, 1 was
normalized.
Test #2 was 13.1 days (on average) after test 1.
■■ Medicated (N=8): 3 children had motion and attention dyscontrol, 5 were normalized.
■■ Not Medicated: For the 20 children had attention and motion dyscontrol, 6 had motion and attention dyscontrol, 4 had motion
dyscontrol only, 5 had attention deficit only and 5 were normalized. 4 had motion dyscontrol only, 2 had attention dyscontrol only, 1 was
normalized.
Success to me is...
...finding the best treatment
plan to help Josh get
back on track.
—
Henry J. Hasson, MD
Pediatric Neurology, Brooklyn, NY
History: Josh is a 7 year old boy in the 1st grade. History and exam
revealed good health. The mother noted that he “kicked a lot more than
his siblings.” His growth and development are age appropriate.
Referral Complaint: His first visit was February 5. He presented with
complaints of hyperactivity and inattention at home and at school. He was
failing quizzes and tests.
Plan of Action: Shortly after Josh’s initial visit, our practice acquired
the Quotient® System. We administered a Quotient ADHD Test while on
Concerta® 27 mg at the first follow-up visit on 2/27. Motion and attention
metrics revealed significant motion dyscontrol, with the disengaged
attention state dominating. His mother reported no improvement in
behavior at home or school. Clinical interview, parent report and Quotient
results all pointed to ineffective medication or sub-therapeutic dose, so we
increased dose to Concerta 36 mg. We repeated Quotient Test on 3/13.
His mother reported that hyperactivity improved, but he could not pay
attention in school or follow directions at home. We increased dose to
Concerta 54 mg. On April 3, the Quotient Test confirmed adequate dosing.
His mother reported that his teachers were happy with his progress. He
“is doing wonderfully” at school and at home, with good motion control
and attention.
Conclusions: This case illustrates the value of using data from serial,
objective assessments using the Quotient® ADHD Test during medication
initiation. The reports help the parent and patient see their progress (or
lack of progress) in a concrete way, which makes the conversation about
next steps more efficient and productive. Objective data helps us to
optimize the treatment plan faster.
Josh, Age 7
Test #1, 2/27
Concerta® 27 mg, 2 hours post-dose
Motion Analysis
Test #1
Test #2
Head Motion
Test #3
Ref. Range
Results
%ile
Results
%ile
Results
%ile
Immobility
Duration
49-152 ms
94 ms
60
131 ms
78
269 ms
95
Movements
1965-5767
3353
53
2333
74
1324
91
Displacement
2.5-10.7 m
6.12 m
45
3.52 m
67
1.81 m
91
Area
51-354 cm2
246 cm2
28
118 cm2
52
81 cm2
67
Spatial
Complexity
1.041-1.130
1.052
32
1.093
72
1.129
83
Temporal
Scaling
0.563-1.244
0.687
60
0.614
80
0.420
94
5 minutes
10 minutes
15 minutes
Metrics were within the reference range. Graphics reveal that performance
deteriorated.
Two of six motion results at baseline were less than the 35 percentile, which may
be clinically significant. Results improved in Test #2 with all metrics above the 50th
percentile. Results improved further in Test #3.
th
Attention Analysis
Test #1
Test #2
Ref. Range
Results
%ile
61.8-90.2%
58.4%
1.3-18.3%
Commission
errors
Incorrect responses
Test #3
Results %ile
Results %ile
11t
60.9%
15t
87.1%
76
43.1%
2
t
36.5%
3
t
3.0%
61
15.6-58.2%
40.0%
43
41.7%
40
22.7%
70
Latency
436-634 ms
692 ms
94
459 ms
20
525 ms
45
Variability
131-238 ms
447 ms
1t
340 ms
2t
157 ms
63
25-48
65
4t
74
2t
30
57
Accuracy
Omission errors
COV
2+ sec
2 sec
1 sec
Test #1: Accuracy, omission errors, variability and COV were <16th percentile at
Test #1. The latency score (692 ms) was just outside the reference range and slow
for his age group. These results suggest that the medication is at a sub-therapeutic
dose.
Test #2: With the exception of commission errors and latency, the attention metrics
are still more than 1 standard deviation from the mean.
Test #3: All metrics are well within the reference range.
Correct responses
2+ sec
2 sec
1 sec
5 minutes
10 minutes
15 minutes
Many omission and commission errors throughout the test, with more omission
errors at end of the test. Slow and variable responses.
Attention State Summary
Test #1
Test #2
Ref. Range
Results
%ile
10 - 18
15
48
13
Attentive
0.0 - 60.0%
0.0%
1
t
Impulsive
13.3-63.3%
13.3%
Distracted
0.0 - 23.3%
Random
Attention State Analysis for 30 Second Segments
Test #3
Results
%ile
70
13
70
0.0%
1
t
43.3%
70
90
16.7%
84
46.7%
39
26.7%
14t
23.3%
17
6.7%
56
0.0 - 43.3%
26.7%
30
33.3%
22
3.3%
75
Minimal
0.0 - 6.7%
33.3%
2
t
26.7%
2
t
0.0%
99
Contrary
0.0 - 3.3%
0.0%
99
0.0%
99
0.0%
99
# Shifts
Results %ile
ATTENTIVE
IMPULSIVE
DISTRACTED
Disengaged
The first two tests, there were 2 parameters <16th percentile and 2 between the
17th and 35th percentile. He had good performance in Test #3.
DISENGAGED
SUMMARY
5 minutes
10 minutes
15 minutes
Distracted and disengaged attention states dominate the test. What else
might cause this?
Test #3 4/3
Concerta® 36 mg, 2 hours post-dose
Concerta® 54 mg, 5 hours post-dose
Head Motion
Head Motion
Motion Results
Test #2, 3/13
10 minutes
15 minutes
Motion Scaled Score improved, but is above the mean for subjects without
ADHD (4.0).
Incorrect responses
15 minutes
Incorrect responses
2+ sec
2 sec
1 sec
1 sec
Correct responses
Correct responses
2+ sec
2 sec
2+ sec
2 sec
1 sec
1 sec
5 minutes
10 minutes
Motion control is good for a 7 year old (high percentile scores, tight motion
pattern throughout.)
2+ sec
2 sec
5 minutes
Response Results
5 minutes
10 minutes
15 minutes
5 minutes
10 minutes
15 minutes
Many omission errors at the beginning and end of the test. Slow/variable
correct responses.
Omission errors reduced. Many commission errors. Improved accuracy from
3-12 minutes.
Attention State Analysis for 30 Second Segments
Attention State Analysis for 30 Second Segments
ATTENTIVE
ATTENTIVE
IMPULSIVE
IMPULSIVE
DISTRACTED
DISTRACTED
DISENGAGED
DISENGAGED
SUMMARY
5 minutes
SUMMARY
10 minutes
15 minutes
Distracted and disengaged attention states dominate the test. Medication is
sub-therapeutic.
5 minutes
10 minutes
15 minutes
Much better on-task behavior (43.3%, 70th %ile). Room for improvement.
Attention State Results
Quotient® ADHD Composite Scores
Test Date
Test #1
Test #2
Test #3
2/27/2011
3/13/2011
4/3/2011
6.89
6.93
6.99
Age
Medication
Concerta
27 mg
System Index
®
Concerta
36 mg
®
Concerta®
54 mg
Likely
Likely
Unlikely
Motion
7.67
5.26
3.58
Attention
9.88
9.75
4.77
Global
8.78
7.50
4.18
Scaled Scores
System Index Key
Unlikely
Possible
Probable
Likely
2.51-5.00
5.01-7.50
7.51-10.00
Scaled Scores Key
0.00-2.50
mean
non-ADHD=4
mean
ADHD=7
Case Summary
February 5: This boy was a new patient.
■■ Presented with complaints of hyperactivity and inattention at home and at school. He was failing quizzes and tests.
■■ Started Concerta 27 mg
February 27:
■■ The first Quotient ADHD Test was administered 3 weeks later while on medication.
■■ Motion and attention metrics revealed significant motion dyscontrol, with Disengaged attention state dominating. Mother
reported no improvement in behavior at home or school.
■■ Clinical interview, parent report and Quotient results pointed to ineffective or sub-therapeutic medication.
■■ Increased dose to Concerta 36 mg.
March 13:
■■ Repeated Quotient Test.
■■ Mother reported that hyperactivity improved, but he still cannot pay attention in school or follow directions at home.
■■ Increased dose to Concerta 54 mg.
April 3:
■■ Quotient Test confirmed adequate dosing.
■■ Mother reported that his teachers were happy with his progress. He “is doing wonderfully” at school and at home, with
good motion control and attention.
1- AAP ADHD Clinical Practice Guideline. Pediatrics, 2011 128(5). 2- AACAP Practice Parameter. J. Am. Acad. Child Adoles.
Psychiatry, 2007 46(7). 3- Data on file. 4- Teicher, J of Child and Adol. Psychopharmacology, 2003 13(1).
© Copyright 2011 F8060 (2011/12/26)
Quotient is a registered trademark of BioBehavioral Diagnostics Company.
Concerta is a registered trademark of McNeil Pharmaceuticals.
877.246.2397
www.BioBDx.com
Success to me is...
...finding medication
to help Scott
focus
after school.
—
Henry J. Hasson, MD
Pediatric Neurology, Brooklyn, NY
History: Scott is a 12 year old boy in the 7th grade. He has been a
patient since July 2010 when I made a diagnosis of ADHD.
Referral Complaint: Scott was doing fairly well on 15 mg Focalin®
XR, but his mother noticed that he became distracted late in the
afternoon and had trouble finishing homework.
Plan of Action: We asked Scott to refrain from taking his medication
on the day of his next visit so we could do a baseline Quotient® ADHD
Test. A baseline test on a new patient gives us quantitative severity
measures in each symptom domain and serves as a benchmark to
guide decision-making about patient management. The baseline test
is also valuable for established patients to determine if deficits are
severe enough to continue medication. Scott’s baseline test showed
good motion control in the first five minutes, but performance
degraded progressively. The mean motion metrics were all at the low
end of the reference range. There were 21 attention shifts. Distraction
and disengagement were the predominant attention states at the
end of the test.
We re-started Focalin XR 15 mg and repeated the Quotient
assessment on March 14. He had excellent motion control, but still
some inattention at school. Inattention was worse at the end of the
day, which suggested that the medication may be wearing off too
early. We switched to Concerta 54 mg to cover late afternoon.
At Scott’s back-to-school visit on October 2, the Quotient Test
confirmed adequate dosing. He returned to school in September
taking his medication. Although I was unaware of it at the time,
because he had a new teacher, the parents decided to try a “no
medication experiment.” The teacher immediately saw a difference
in behavior and called the parents to report the problems.
Conclusions: This case illustrates the value of using data from
serial, objective assessments using the Quotient® ADHD Test to inform
medical management of the patient and help to achieve better clinical
efficacy. We can confirm suspicions of medication wearing off and
adjust by adding a dose later in the day or by changing to a longer
acting medication, as we decided for Scott.
Scott, Age 12, Grade 7
Test #1, 3/6
No medication
Motion Analysis
Baseline
Test #2
Head Motion
Test #3
Ref. Range
Results
%ile
Results
%ile
Results
%ile
Immobility
Duration
98-324 ms
146 ms
43
575 ms
97
418 ms
91
Movements
906 - 3013
2649
22
525
98
718
91
1.18-4.42 m
3.59 m
25
0.57 m
99
0.78 m
94
23-118 cm2
91 cm2
34
10 cm2
98
11 cm2
96
Spatial
Complexity
1.099-1.317
1.147
38
1.442
94
1.413
91
Temporal
Scaling
0.355-0.801
0.726
25
0.131
97
0.265
91
Displacement
Area
5 minutes
10 minutes
15 minutes
Metrics were at the low end of the reference range. Area increased over time.
Four of six motion results at baseline were less than the 35 percentile, which
may be clinically significant. The age/gender matched percentile scores improved to
>90th percentile in Test #2 and Test #3.
th
Attention Analysis
Baseline
Test #2
Ref. Range
Results
%ile
72.4-95.8%
79.3%
Omission errors
0.4-13.8%
Commission
errors
Accuracy
Latency
Variability
COV
Incorrect responses
Test #3
Results %ile
Results %ile
26
92.4%
66
94.9%
81
15.2%
15
t
5.3%
32
2.2%
48
7.7-45.7%
25.7%
36
9.7%
77
8.1%
81
366-532 ms
486 ms
69
517 ms
80
499 ms
76
88-183 ms
164 ms
24
122 ms
49
95 ms
70
20-39
33
26
23
67
19
86
Test #1: Omission errors were <16th percentile at Test #1.
Test #2: Attention metrics improved, but the graphic reveals that the number of
omission errors increased at in the last 5 minutes of the test.
Test #3: All metrics are within the reference range.
2+ sec
2 sec
1 sec
Correct responses
2+ sec
2 sec
1 sec
5 minutes
10 minutes
15 minutes
Appropriately attentive responses in the first 5 minutes, with some commission
errors. Latency and omission errors increase at end.
Attention State Summary
Baseline
Test #2
Ref. Range
Results
%ile
5 - 18
21
7t
16
Attentive
10.0-90.0%
26.7%
28
Impulsive
6.7 - 53.3%
40.0%
Distracted
0.0 - 15.0%
Random
Attention State Analysis for 30 Second Segments
Test #3
Results
%ile
34
3
92
66.7%
61
90.0%
83
35
16.7%
69
10.0%
79
20.0%
11t
16.7%
16t
6.7%
56
0.0 - 20.0%
6.7%
34
0.0%
99
0.0%
99
Minimal
0.0 - 3.3%
6.7%
12
t
0.0%
99
0.0%
99
Contrary
0.0 - 0.0%
0.0%
99
0.0%
99
0.0%
99
# Shifts
Results %ile
ATTENTIVE
IMPULSIVE
DISTRACTED
Disengaged
In Test #1, there were many attention state shifts (21, 7th percentile) and the
percentage of time in the Attentive state was low (26.7%, 28th percentile.
Metrics improved in Test #2 and was excellent in Test #3.
DISENGAGED
SUMMARY
5 minutes
10 minutes
15 minutes
The Impulsive state results from many commission errors. The patient was
Distracted/Disengaged for most of the last 5 minutes.
Test #3, 10/2
Focalin® XR 15 mg, 4 hrs post-dose
Concerta® 54 mg, 1.5 hrs post-dose
Head Motion
Head Motion
Motion Results
Test #2, 3/14
10 minutes
15 minutes
Excellent motion control.
Incorrect responses
15 minutes
10 minutes
15 minutes
Incorrect responses
2+ sec
2 sec
1 sec
1 sec
Correct responses
Correct responses
2+ sec
2 sec
2+ sec
2 sec
1 sec
1 sec
5 minutes
10 minutes
Excellent motion control.
2+ sec
2 sec
5 minutes
Response Results
5 minutes
10 minutes
15 minutes
5 minutes
Improved attentive behavior, with omission errors at the low end of the
reference range for age/gender.
Very good attentive behavior.
Attention State Analysis for 30 Second Segments
Attention State Analysis for 30 Second Segments
ATTENTIVE
ATTENTIVE
IMPULSIVE
IMPULSIVE
DISTRACTED
DISTRACTED
DISENGAGED
DISENGAGED
SUMMARY
5 minutes
SUMMARY
10 minutes
15 minutes
16 ttention state shifts is a pattern consistent with ADHD. Distracted state is at
the 16th %ile for a 12 year-old boy.
5 minutes
Very good Attentive behavior.
10 minutes
15 minutes
Attention State Results
Quotient® ADHD Composite Scores
Test #1
Test #2
Test #3
3/6/2011
3/14/2011
10/2/2011
12.84
12.91
12.97
Medication
None
Focalin XR
15 mg
Concerta®
54 mg
System Index
Likely
Unlikely
Unlikely
Motion
5.51
2.03
2.30
Attention
8.20
6.10
3.74
Global
6.85
4.07
3.02
Test Date
Age
®
Scaled Scores
System Index Key
Unlikely
Possible
Probable
Likely
2.51-5.00
5.01-7.50
7.51-10.00
Scaled Scores Key
0.00-2.50
mean
non-ADHD=4
mean
ADHD=7
Case Summary
This boy has been in the practice since July. He was stable on Focalin XR 15 mg. Teacher and parent
reports were positive.
March 6:
■■ A baseline Quotient ADHD test was administered without medication.
■■ Mother wanted to confirm that medication was still needed.
■■ The motion pattern showed good control in the first five minutes with progressive degradation.
The mean motion metrics were all at the low end of the reference range.
■■ There were 21 attention shifts. Distraction and Disengagement were the predominant attention
states at the end of the test.
■■ We re-started Focalin XR 15 mg.
March 14: Repeated Quotient Test.
■■ Excellent motion control, but still some inattention at school.
■■ Inattention was worse at the end of the day, which indicated that the medication may be
wearing off early.
■■ Switched medication to Concerta 54 mg to cover late afternoon.
October 2: Quotient Test confirmed adequate dosing.
■■ The boy returned to school taking his medication. Because he had a new teacher, the parents
decided to try a “no medication experiment.” The teacher immediately saw a difference in
behavior and called the parents to report the problems.
Conclusions
■■ Objective testing reduced time to medication optimization from approximately 3-6 months to 4-8 weeks
■■ Baseline testing off medication quantifies the severity of deficit and makes the conversation with the parent
and patient more efficient and productive.
■■ Reassessments at 1-2 week intervals during medication initiation helps to guide treatment decisions and can
help to achieve optimal dosing faster.
■■ Repeat tests inform decisions when considering changing medication or adjusting dose.
■■ Back-to-school assessments confirm that medication is still needed to control symptoms.
© Copyright 2012 F8074 (2012/04/05)
Quotient is a registered trademark of BioBehavioral Diagnostics Company.
Focalin is a registered trademark of Novartis Pharmaceuticals. Concerta is a
registered trademark of McNeil Pharmaceuticals.
877.246.2397
www.BioBDx.com