The TOVA Company

January 16, 2013

© Copyright 2007, 2008, 2011 The TOVA Company, All Rights Reserved.

Test Of Variables of Attention (abbreviated T.O.V.A.) is a registered trademark of The TOVA Company.

No part of this manual may be distributed without permission of The TOVA Company.

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Printed in the United States of America.

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Table of Contents Page

I Introduction 1

1 Terms and Concepts Used in This manual 1

2 Attention-Deficit Hyperactivity Disorder (ADHD) 2

2.1 ADHD and DSM IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.1.1 Sub-Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.1.2 Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.1.3 Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.2 Causes of Off-Task Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.3 Diagnosis of ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.4 Treatment of ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.5 Medication for ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.5.1 Commonly Used Stimulant Medications . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.5.2 Common undesirable effects of stimulant medication . . . . . . . . . . . . . . . . . . 9
2.5.3 Rare undesirable effects of stimulant medication . . . . . . . . . . . . . . . . . . . . . 9
2.5.4 Predicting and measuring response to stimulants medication . . . . . . . . . . . . . 9
2.5.5 Dosage considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.5.6 Non-stimulant medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.5.7 Assessing and monitoring effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

3 Continuous Performance Tests (CPTs) 12

3.1 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.2 CPT variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.2.1 Response Time Variability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.2.2 Correct Response Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.2.3 d0 or Response Sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.2.4 Errors of Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.2.5 Errors of Omission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.2.6 Anticipatory Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.2.7 Post-Commission Response Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.2.8 Multiple Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.3 Significant features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.3.1 Stimuli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.3.2 Presentation of stimuli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.3.3 Practice vs. novelty effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.3.4 Length of test and subtests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.3.5 Norms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.3.6 Distractions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.3.7 Timing Accuracy of CPTs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4 The T.O.V.A. 20
4.1 Construction of the T.O.V.A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.2 Sensitivity and Specificity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.3 Test-Retest Reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.4 T.O.V.A. Formulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.5 Screening Version . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.6 Clinical Version . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4.7 Administering the T.O.V.A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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 4.7.1 Pre-test Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

II Interpreting the T.O.V.A. 26

5 Factors Affecting T.O.V.A. Performance 26

6 The T.O.V.A. Report 27

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Analyzed Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Analyzed Data (Graphs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Tabulated Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Raw Data (Graphs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Raw Data (Tables) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Error Graphs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Reaction Time Histogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

7 Individualized Success Strategies: School 48

8 Individualized Success Strategies: Home 48

9 T.O.V.A. ® Protocols 48

III Appendices 70

10 T.O.V.A. Observer Rating Form 70

11 DSM IV Symptom Checklist 71

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T.O.V.A. Clinical Manual 1 TERMS AND CONCEPTS USED IN THIS MANUAL

Part I

Introduction

The T.O.V.A.

The Test of Variables of Attention® is an objective, standardized, and highly accurate continuous perfor-
mance test (CPT) that is used to measure attention and impulsivity. The Visual T.O.V.A. and Auditory
T.O.V.A. are non-language-based, sufficiently long (21.6 minutes), computerized tests that require no left-
right discrimination or sequencing. Responses are recorded with a specially designed, highly accurate (±1
ms) electronic microswitch.

The T.O.V.A. measures key components of visual and auditory attention. These measurements are then
compared to those of a group of people with attention disorders and a group without. The T.O.V.A. can also
establish a personal baseline of attention for future comparison or track response to treatment, including
medication. It can even flag possible symptom exaggeration.

1 Terms and Concepts Used in This manual

Attention, according to Merriam-Webster’s dictionary is a) the act or state of applying the mind to some-
thing, and b) a condition of readiness for such attention involving especially a selective narrowing or
focusing of consciousness or receptivity.
Attention is a mainstay of life and the ability to focus one’s attention has a determination on one’s
success in school, at work, and in relationships.

Off-task behavior is a descriptive term with no specific etiologic or diagnostic implications. It is used in
this manual to indicate that persons are not engaged in the appropriate or assigned task when it is
reasonable to expect that they should be. They are not on-task for reasons that may have nothing to
do with attention disorders.

Attention-Deficit Hyperactivity Disorder (ADHD) refers to a specific symptom complex defined in the
current manual of diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition
(DSM-IV).

Target symptoms and measures refer to the particular symptoms that are specified for treatment and the
particular measures being used to determine the effectiveness of that treatment. In this manual,
attentional characteristics (specifically those variables measured by the T.O.V.A.) and hyperactivity
are evaluated and treated separately.

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T.O.V.A. Clinical Manual 2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

2 Attention-Deficit Hyperactivity Disorder (ADHD)

2.1 ADHD and DSM IV

2.1.1 Sub-Types

Four sub-types of ADHD are defined in DSM-IV:

Predominantly Inattentive Type (314.00) – Must have six or more of the following symptoms for six months
or more:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, and other
activities

• Often has difficulty sustaining attention in tasks and play activities

• Often does not seem to listen when spoken to directly

• Often does not follow through on instructions and fails to finish school work, chores, or duties in the
workplace (but not due to oppositional behavior and not because of a failure to understand)

• Often has difficulty organizing tasks and activities

• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as
schoolwork or homework)

• Often loses things necessary for tasks or activities (e.g. toys. school assignments, pencils, books, or
tools)

• Often easily distracted by extraneous stimuli

• Often forgetful in daily activities

Predominantly Hyperactive-Impulsive Type (314.01) – Must have six or more of the following symptoms
for 6 months or more:

• Hyperactivity
– Often fidgets with hands or feet or squirms in seat
– Often leaves seat in classroom or in other situations in which remaining seated is expected
– Often runs about or climbs excessively in situations in which remaining seated is expected (in
adolescents and adults, may be limited to feelings of restlessness)
– Often has difficulty playing or engaging in leisure activities quietly

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T.O.V.A. Clinical Manual 2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

– Often “on the go” or often acts as if “driven by a motor”

– Often talks excessively

• Impulsivity
– Often blurts out answers before questions have been completed
– Often has difficulty awaiting turn
– Often interrupts or intrudes on others (e.g., butts into conversations or games)

Combined Type (314.01) – Must meet criteria for both inattentive and hyperactive/impulsive types for six
months or more

ADHD Not Otherwise Specified (314.9) – Criteria for other subtypes are not met, but symptoms are judged
to interfere with the affected individual’s functioning for six months or more. This category typically used for
adults with ADHD.

2.1.2 Requirements

To qualify for the diagnosis of ADHD, the following criteria must be met:

• Onset of symptoms no later than seven years of age

• Symptoms must be present in two or more situations

• There must be clinically significant distress or impairment in social, academic, or occupational func-
tioning

• Condition cannot be exclusively part of a pervasive developmental disorder, schizophrenia, or other

psychotic disorder and is not better accounted for by a disorder of mood, anxiety, dissociation, or
personality

2.1.3 Issues

Conceptually, the diagnostic category, “ADHD”, has many limitations.

• The symptoms are subjective, unreliable, and culture-bound.

• ADHD is really a symptom complex, not a disorder (that, by definition, must have a single, common
etiology and a predictable natural history and response to treatment).

• The assumption that hyperactivity and attention deficits are necessarily linked is misleading and an
artifact of equating symptom complexes with disorders. (This isn’t the only example in psychiatry and

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T.O.V.A. Clinical Manual 2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

psychology of a hypothetical construct being treated as though it had an independent existence in the
real world).

• The requirement that the onset be by seven years of age ignores some critical factors. As examples,
many non-hyperactive, inattentive children and children with strong external support systems are not
symptomatic until later.

• Since behavior is situationally specific, attention deficits may not be apparent in more than one setting.
Differences in setting (school, classroom, teacher, peers) may affect the presence of symptoms.

• Although the emphasis is on inattention, individuals with ADHD are highly variable in their attention
over time, and can hyperfocus.

• There is no mention of the status of the Central Nervous System; that is, brain damage can cause
ADHD in DSM-IV.

• Criteria specifically applicable to adults is lacking.

• Executive functions are not included.

2.2 Causes of Off-Task Behavior

Differential diagnosis for off-task behavior includes the following:

• Normal behavior
Age-appropriate behavior that is mislabeled, e.g., “active alert” children or unrealistic adult expecta-
tions of normal development

• General medical problems

Such as anemia, hyperthyroidism, otitis media, and dietary inclusions/sensitivities

• Medications
Such as anticonvulsants, antihistamines, and psychodepressants that sedate or slow the brain

• Toxic conditions
Such as environmental exposures, drugs, or an illness

• Sensory deficits and hypersensitivities

Such as unrecognized hearing and visual impairments and any sensory (including olfactory and kines-
thetic) hypersensitivity

• Neurologic problems (other than ADHD)

Such as sleep disturbances (including apnea and narcolepsy), seizures, dementia, and Traumatic

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T.O.V.A. Clinical Manual 2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

Brain Injury

• Family style and organization

This may include social and cultural factors

• School readiness, learning style, and motivation

Some children (including those with ADHD) have a hands-on rather than a listen & understand learn-
ing style

• Stress
Resulting from emotional trauma and overwhelming situations

• Intellectual impairment and precocity

• Learning disabilities
One third of individuals with an attentional disorder also have a learning disability, and vice versa

• Psychiatric conditions
Such as PTSD, psychosis, bipolar or obsessive-compulsive traits/disorders, depression, PDD, ODD,
dementia, conduct disorder, and reactive attachment disorder and/or anxiety

• Substance use, abuse, and withdrawal

All substances, including caffeine and nicotine

• ADHD (see below)

Note: These causes are not mutually exclusive. As noted above, 30% of individuals with ADHD
(including adults) have a learning disability (and vice versa), and between 40-65% of substance
abusers have ADHD. In addition, untreated individuals with ADHD often develop low self-esteem,
depression, and acting out which may obscure the underlying ADHD.

2.3 Diagnosis of ADHD

The components of a diagnostic workup for ADHD may include:

• History: Nothing (not even the T.O.V.A.) replaces a detailed personal and family history.

• Physical exam: A recent exam by a primary care provider is important.

• Psychological/neuropsychological assessment: There should be emphasis on learning style, cog-

nitive assets and liabilities, and CNS functioning

• Evaluation of classroom/workplace behavior and performance: Direct observations or telephone

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T.O.V.A. Clinical Manual 2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

interview of teacher or supervisor are very helpful, especially to prepare them for recommendations.

• Mental status examination/personality assessment: This helps identify comorbid and/or other
conditions (such as depression).

• Behavior ratings for children—including the Vanderbilt, ACTeRS, the ASEBA, and BASC 2—are
especially useful. Behavior ratings for adults include the BAARS-IV, the ASEBA, and the BAADS.
While behavior ratings are an important part of the diagnostic process, they are best used in conjunc-
tion with objective measures like the T.O.V.A. to minimize the effects of rater bias and overemphasis
of disruptive behaviors.

• DSM-IV Symptom checklists: These checklists help clinicians to thoroughly review all symptoms of
ADHD.

• T.O.V.A.: The T.O.V.A. objectively measures visual and auditory attention, variability, response time,
and impulsivity, which can be affected by many factors; however, the T.O.V.A. does not make a
diagnosis. The clinician needs to make use of the objective results in the context of the full clinical
picture. There will be more about this in the review of sensitivity and specificity.

Note: A comprehensive work-up that includes all or most of the components above may not be
feasible or cost-effective. The clinician must decide which steps are needed and in what sequence.

2.4 Treatment of ADHD

Figure 1 illustrates the underlying neurophysiological problem in ADHD by comparing the subject’s original
baseline visual T.O.V.A. to his response to treatment—in this case, medication. The effects of 5 mg of
methylphenidate on the T.O.V.A. tests of a physician with an attention deficit are represented. Shown
are the mean response time histograms of the responses to the visual T.O.V.A. target stimuli. The mean
response time of 580 ms in the test without medication is significantly slower than the normal for an adult.
Indeed, 580 ms is normal for six-year-old boys. In contrast, the mean response time of 340 ms in the test
given 1.5 hours after 5 mg of methylphenidate is normal for an adult.

Figure 1: Response time histogram of a subject, on- and off-medication

The treatment intervention is generally multifaceted, reflecting the many symptoms of ADHD and possible

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T.O.V.A. Clinical Manual 2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

comorbid conditions. Although the T.O.V.A. can be used to measure treatment effects on attention, variabil-
ity, response time, and impulsivity, we do not advocate treating the T.O.V.A. and losing sight of the person
in the real world.

A number of methods are currently being used to treat the symptoms of ADHD. These include:

• Providing information about ADHD and techniques to manage inattention and behavior
Confirming the diagnosis is sometimes sufficiently therapeutic, in and of itself. Even with the diag-
nosis, some cases are mild enough or the life circumstances (particularly for adults) are such that
education and awareness are the only treatment necessary. In some cases, other treatment may be
provided on an as-needed basis, for example when extensive reading is necessary.

• Individual/parental/spousal counseling and coaching to improve management techniques

There are many management or coping strategies that can reduce the problems to a more man-
ageable size: reduction of distractions, breakdown of tasks into shorter units, time-limited activities,
time-management techniques, memory-enhancing activities, positive toward-task redirection, relax-
ation exercises, etc.

• School/workplace consultation
Use of the T.O.V.A. Individualized Home and School Success Strategies can be very helpful in the
classroom setting and in the home. Findings need to be translated into relevant suggestions like a
private office space or a quiet homework area for a distractible person, etc.

• Vocational considerations
While we want to avoid self-fulfilling prophesies, attentional characteristics should be considered when
counseling about vocational opportunities. As an example, some persons with ADHD should be
advised to consider occupations that are active and varied, rather than tedious and repetitive. Some
individuals with ADHD tend to do well in a computer-related vocation.

• Recreational considerations
Consider faster-paced activities like swimming and handball instead of slowly paced activities.

• Neurofeedback
Using a pre- and a post-treatment T.O.V.A. (along with other measures), many clinicians working
with individuals with ADHD are reporting dramatic responses to these treatments. A number of well-
designed collaborative studies with the T.O.V.A. are now underway, and we expect to learn more about
the indications, types, and outcome of neurofeedback in the near future.

• Behavior modification
These types of treatment are extensively described in the literature. However, it should be noted that
they are especially useful in the treatment of impulsivity/disinhibition.

• Psychotherapy
This treatment is indicated with related self-defeating coping strategies and comorbid issues such as
depression, substance abuse, anxiety, ODD, and others.

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T.O.V.A. Clinical Manual 2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

• Natural Remedies
Continued research indicates there may be gains from Omega 3 fatty acids, vitamins, homeopathic
remedies, natural supplements, meditation, martial arts, brain development programs and exercises,
and others. Use of the T.O.V.A. provides an objective measure to the effectiveness of the treatment.

• Medication
See the section below.

2.5 Medication for ADHD

Note: It is beyond the scope of this brief introduction to give extensive details about the pharma-
cotherapy of children and adults. For more information we recommend having and reading one of
the handbooks written on this subject.

As with any intervention, it is important to determine exactly what symptoms to target for treatment, and to
select appropriate measures of these symptoms. With the availability of CPTs like the T.O.V.A., the clinician
can now specifically target attentional variables and reliably, objectively measure medication effects. Be-
havior ratings alone may not be sufficiently sensitive enough to be used to determine optimal dosage levels
in the treatment of inattention.

Although antidepressants may be prescribed to treat ADHD, especially in cases with comorbid substance
abuse, they may not be as effective as stimulant medication on attention. The T.O.V.A. is used to measure
individual performance on antidepressants as well as with stimulants.

2.5.1 Commonly Used Stimulant Medications

• Methylphenidate is the most frequently prescribed stimulant medication. Since the strength of the
generic (MPH) form can be ±20% of Ritalin™ , switching from one to the other can be problematic.
Ritalin SR (sustained release)™ and Ritalin LA (long acting) often has an uneven release over time
in our experience. In contrast, Concerta™ has a much smoother release over time and is particu-
larly useful when taking a noon dose is inconvenient (e.g., having to go to the school nurse’s office)
or problematic (e.g., forgetting to take the medication). Focalin™ (with liquid and tablet forms) and
Daytrana™ (the patch) appear quite promising, especially when small doses are prescribed.

• Dextroamphetamine (D-A) is twice as potent as MPH. Thus, 5 mg of D-A is roughly equivalent to

10 mg MPH. As with MPH, generic D-A may be less powerful than Dexedrine™ . D-A appears to
have a higher incidence of side effects (the same side effects as MPH). D-A and MPH are thought
to be equally effective. D-A is often the preferred medication for patients with seizures since it may
lower seizure threshold less than MPH. Dexedrine Extendtabs™ (the slow release form of Dexedrine)
appear to have a more even release mechanism. Short-acting MPH or D-A is used with Extendtabs
to provide more even coverage, particularly in the late afternoon.

• Adderall™ , a mixture of long- and short-acting amphetamines and d-amphetamines, is long-acting,

has little to no rebound, and is easy to divide into small doses.

• The recently approved Vyvanse™ is a “pro-drug” that is converted into an active stimulant in the

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T.O.V.A. Clinical Manual 2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

intestine and, thus, is less likely to be abused.

• Magnesium pemoline (Cylert™ ) is no longer generally available because of serious side effects (such
as liver damage).

NOTE: Since most recommendations about dosing are based on behavior ratings and body weight,
dosing may be excessive, particularly if the targeted symptom is inattention.

2.5.2 Common undesirable effects of stimulant medication

Bothersome but not serious side effects can include decreased appetite, weight loss, abdominal pain, sleep
disturbance (or increase), and afternoon irritability (“rebound”), which are often handled by a reduction in
dosage, administration of medication just before meals, or the addition of a smaller dose in the afternoon to
reduce “rebound”. Irritability, tiredness, or feeling “jumpy” or “edgy” are frequently encountered side effects
when a teenager or adult is given too much medication.

2.5.3 Rare undesirable effects of stimulant medication

Less common effects may include tics, hypertension and tachycardia, temporary height suppression, and
sadness or depression, for which reassessment of the medication and dosage are promptly indicated. The
use of stimulant medication in persons who also have a tic or seizure disorder is controversial but is effective
in many cases.

2.5.4 Predicting and measuring response to stimulants medication

Comparing the baseline (no medication) T.O.V.A. and a T.O.V.A. 1.5 to 2.5 hours after a single dose of
medication, one can predict whether there will be a good response to medication and determine a good
beginning dosage.

However, since patterns of behavior tend to change slowly, a clinical trial of medication is needed to ascer-
tain the degree of response. It is not possible to predict response to antidepressants in the same way since
they can take 3-4 weeks to build up.

A double-blind clinical study of the effects of MPH on attention and impulsivity was conducted with 154
children with ADHD. 143 children were MPH responders and 11 were non-responders.

While both groups showed some improvement in T.O.V.A. performance with MPH, only the responders
obtained a significant improvement (Figure 2).

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T.O.V.A. Clinical Manual 2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

Figure 2: Methylphenidate responders and nonresponders.

2.5.5 Dosage considerations

With the availability of the T.O.V.A., the effects of different dosages can be very accurately measured to
obtain the best effects on attention. Use of the T.O.V.A. in clinical practice has resulted in a dramatic
increase in efficacy (95%), decrease in dosage levels (50%), low incidence of side effects (<5%), and
higher compliance. The decrease in dosage reflects the literature indicating that low doses of stimulant
medication affect attention, that high doses affect behavior, and that there is either little overlap between
the two effects, or that attention actually worsens with high doses (Figure 3).

Figure 3: Schematic representation of psychostimulant dosage effects on attention and behavior.

In treating attention disorders, it is important to carefully determine target symptoms and the means of mea-
surement. For example, low-dose methylphenidate (MPH) affects attention primarily, while higher doses
affect behavior primarily and may affect attention adversely. If one were only to use subjective sources of
data (i.e.: history and behavior rating scales) to determine response to treatment, the effects on attention
could be missed.

2.5.6 Non-stimulant medications

• Atomoxetine (Strattera™ ) appears primarily useful in the treatment of problems of executive function.
Use the T.O.V.A. to compare on- and off-medication responses.

• Guanfacine (Intuniv™ ), an antihypertensive medication, was recently approved for use in ADHD, and
initial studies are encouraging.

• Wellbutrin™ and other antidepressants are prescribed for ADHD in cases with depression and/or
concern for potential substance abuse with stimulant medication.

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• When a stimulant medication is used to treat an attention problem, Clonidine™ or Depakote™ may
be considered in addition.

2.5.7 Assessing and monitoring effects

Since optimal medication dosage can change over time, children and teenagers may need to be re-
evaluated every six months and adults once a year. It is recommended that the clinician obtain periodic
interim history (including undesirable treatment effects), parent/classroom/self behavior ratings, a new base-
line (no medication) T.O.V.A., and a new on-medication T.O.V.A. Evaluate results and determine whether to
continue or change treatment.

Below are two illustrations of the use of the T.O.V.A. and behavior ratings to monitor clinical course over
time. In the first case of a child diagnosed with ADHD, she gradually improved, and her T.O.V.A. and
behavior ratings normalized by age 10 1/2 (Figure 4). The two subsequent evaluations, which documented
her improvement, were obtained because of a research protocol. As would be true for any person who
“outgrows” ADHD, the last two off-medication T.O.V.A.’s were within normal limits, and the on-medication
T.O.V.A.’s improved but not significantly.

Figure 4: Outgrowing the need for medication: on- and off-medication trials over time.

The second illustration documents the clinical course of another girl diagnosed with ADHD who did not
improve by 11 1/2 (Figure 5). She may prove to be one of the 50% who do not “outgrow” her ADHD.

Figure 5: Continued need for medication: on- and off-medication trials over time.

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T.O.V.A. Clinical Manual 3 CONTINUOUS PERFORMANCE TESTS (CPTS)

3 Continuous Performance Tests (CPTs)

3.1 History

Rosvold and his group introduced the CPT in the mid-1950s. His CPT was a sequential, visual, language
based A-X task in which the subjects responded whenever they saw an “A” followed by a “X”. Since that
time, many CPTs have been created primarily for use in research projects, but a few have been made
available commercially for researchers, schools, and clinicians. Research with early CPTs did not show
very promising results. These CPTs focused on omission and commission scores with inaccurate measures
of response time. We know that accurate Response Time (RT) and Variability of RT are critical for CPTs
to be sensitive and useful. Only the T.O.V.A. tests have been extensively normed and have highly accurate
(pm1 ms) and sensitive response time measures.

The T.O.V.A. began as a large electronic rack with a tachistoscopic shutter in our first clinical study in 1966.
It was nicknamed “Herman” by one of the children. With an accuracy of pm100 ms, the CPT results were
significant and documented the efficacy of stimulant medication (dextroamphetamine) in comparison with a
tranquilizer (chlorpromazine) in the treatment of hyperkinetic children. It is noteworthy that the classroom
behavior rating (the Conners Parent-Teacher Questionnaire) was not useful in discriminating medication
effects. Perhaps the most important outcome of this initial study was the necessity to target inattention and
hyperactivity separately, and to develop appropriate tools to measure each.

With the advent of the Apple IIe in the late 70s, the current design (with two test conditions, see below) and
the research-quality microswitch were created. It was initially named the “MCA” (or Minnesota Computer
Assessment). However, a potential copyright conflict arose, and the MCA became the Test Of Variables of
Attention (T.O.V.A.). As the T.O.V.A., it was normed and used in a number of clinical trials before its release
in the mid-80s.

Since then, we have continued to upgrade the test by making it more user friendly, collecting additional
subjects to have year by year norms for children, and adding signal detection indices for a comparison
ADHD score. The School Intervention Report and Version 7.0 with an improved scoring and interpretation
system were completed in 1996 when the Auditory T.O.V.A. was released. Additional norming studies and
programmatic enhancements, including the Home Intervention Report, led to the release of Version 7.3 in
2007. In 2008, the Symptom Exaggeration Index was developed. In 2011, version 8 was released with
several changes and new hardware. The Symptom Exaggeration Index was embedded in the report, the
ADHD score was reworked and became the Attention Performance Index (API) and additions were made
to the Home and School Intervention Reports which were renamed the Individualized Success Strategies-
Home and School.

3.2 CPT variables

Fourth-generation CPTs, like the T.O.V.A., accurately measure far more significant variables of both audi-
tory and visual information processing than the earlier CPTs. Length of the test (or subtest) makes a big
difference since some individuals with ADHD can “rise to the occasion” and do well enough for a short time.
Different CPTs may label these variables somewhat differently, making comparisons difficult. It is also true
that even when variables have the same labels, the characteristics of the different CPTs may be so different
that they are actually measuring very different things. Of course, the variables also have different values
within a CPT when there are two or more test conditions such as infrequent and frequent target presen-
tation modes, or when the inter-stimulus interval changes. In addition, we must keep in mind that labeling

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something doesn’t mean that the variable is actually measuring what we think that it’s measuring.

The following variables are important for CPTs to measure, and T.O.V.A. includes them:

3.2.1 Response Time Variability

Response Time Variability is a measure of variability (consistency) of response time and is the standard
deviation of correct response times (that is, the time in ms taken to respond correctly to a target). Indi-
viduals with ADHD tend to be inconsistent—they may be able to perform within normal limits for a while,
but they “lose it” much sooner than others. As parents frequently note, a child with ADHD can focus (even
“hyperfocus”) and stay on task some times, particularly when the task is very interesting and fast paced (like
a computer game). Since Response Time Variability is the single most important measure of the T.O.V.A.
(accounting for >80% of the variance), the timing measurements must be very accurate; hence, the need
for an accurate microswitch rather than rely on the significantly less accurate mouse button or keyboard.

3.2.2 Correct Response Time

Correct Response Time is the processing time (in ms) taken to respond correctly to a target. Counter-
intuitively, individuals with ADHD often have slower than normal response times as well as faster ones. This
measure is one of the more important ones in the T.O.V.A., especially in the first (or boring) half, accounting
for >12% of the variance.

3.2.3 d0 or Response Sensitivity

d0 or Response Sensitivity (the ratio of hit rate to false alarm rate) is a measure derived from Signal Detection
Theory. It is a measure of performance decrement, the rate of deterioration of performance over time. Most
individuals tend to fatigue over time, especially with a boring task. The performance of individuals with
ADHD deteriorates faster than others. d0 helps to distinguish individuals with ADHD from those without
ADHD and accounts for 6% of the variance in the T.O.V.A.

3.2.4 Errors of Commission

Errors of Commission are a measure of impulsivity and/or disinhibition and occur when the subject incor-
rectly responds to the nontarget; that is, the subject pushes the button when they shouldn’t have. In the
T.O.V.A., commission errors are far more frequent in the second half (high response demand). Since exces-
sive errors of commission can affect the other variables, they are also an important measure of test validity.
Generally, excessive commission errors decrease omission errors, shorten response times, and increase
variability. When a report states that the results are ‘invalid’ because of excessive commission scores, it
means that we must interpret the results cautiously since the other variables may or may not be valid. Of
course, excessive impulsivity is a hallmark of ADHD.

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3.2.5 Errors of Omission

Errors of Omission are a measure of inattention and occur when the subject does not respond to the
designated target; that is, the subject omits pressing the button when a target appears or is sounded.
Because the T.O.V.A. covers a broad age span (4-80+), omissions in the visual (but not auditory) test have
a ceiling effect in adults. That is, the task is too easy for adults without ADHD who rarely make omission
errors. On the other hand, omission errors are a sensitive measure in children, teenagers, and the elderly.
When evaluating omissions, always look at the absolute or raw numbers. In some cases one or two errors
reach statistical significance yet there may be little or no clinical significance. As an example, a single error
early in quarter 1 may signify that the subject was surprised when the test began even though the practice
session preceded the test.

It is important to review the Tabulated Data form of the T.O.V.A. report to identify how many omission
errors occurred. Always interpret standard score (or standard deviation) data along side actual raw data to
determine clinical significance of the results.

3.2.6 Anticipatory Responses

Anticipatory Responses (AR) are a measure of impulsivity, guessing which stimulus is presented, or of a
different game strategy in which the subject may be trying to “kill” any stimulus as soon as possible. An
AR occurs whenever a response (pressing the microswitch) is made between 150 ms before and 150 ms
after any stimulus (target or non-target) appears or, in the case of the Auditory T.O.V.A., any stimulus is
heard. Most persons need more than 150 ms to distinguish between a target and a non-target and to
respond by pressing the microswitch; hence, the use of the word “anticipatory”. ARs are not included in the
calculations of errors, response times, and variability. Since excessive anticipatory responses can affect
the other variables, they are also an important measure of test validity. Generally, excessive anticipatory
responses decrease omission errors, increase commission errors, shorten response times, and increase
variability.

To prevent what may be incorrect interpretations, the T.O.V.A. Summary page labels the variables in any
quarter with excessive ARs (equal or exceeding 10%) as possibly “invalid” and needing to be cautiously
interpreted.

While we don’t want to confuse you (any further), it now turns out that there is a fourth reason why some
people have excessive ARs. Some people are much, much faster than most people. They are so fast that
they can accurately respond to the targets in less than the usual 150 ms, avoiding the non-targets. Thus,
when you examine the ratio of target to non-target ARs, you’ll find that these people have very few non-
target ARs. Most if not all of their ARs are with targets. Since the presentation of stimuli is randomized,
they can’t be guessing. They are really processing the information and responding significantly faster than
others.

As you might expect, some experienced computer game players, musicians, and athletes can perform so
well that their correct responses can fall into the AR range, and their test results are labeled as possibly
invalid by the interpretation program because of the excessive ARs.

Recognizing that some tests with excessive ARs should not be invalidated, we recommend that when there
are excessive ARs that the clinician examine the target : non-target ratio for ARs (Tabulated Data), and not
invalidate those quarters in which the ratio is better than 1 target : 3.5 non-targets in quarters 1 and 2 or
better than 3.5 targets : 1 non-target in quarters 3 and 4. In other words, a really fast and accurate person

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will perform better than the ratio of targets to non-targets in that quarter.

3.2.7 Post-Commission Response Time

Post-Commission Response Time is the response time immediately following a commission error. Clinical
observations (but not carefully conducted research) indicate that most people (including individuals with
ADHD) recognize when they make a commission error, and slow down for the next response. It is note-
worthy that a group of conduct disordered youngsters (without ADHD) either did not slow down or actually
responded faster than their average response time. Thus, this may be a way to distinguish individuals with
ADHD only from individuals with a conduct disorder only, but not the comorbid condition. Rarely, some
highly motivated individuals increase their focus, speed up after a commission error, and become more
accurate. A post T.O.V.A. interview with the subject may help to clarify the reason for fast post-commission
response times and adds depth to the clinical picture.

3.2.8 Multiple Responses

Multiple Responses are considered to be a reflection of neurological status. Excessive multiple responses
(>20/test) do not alter or invalidate the other variables, but they do appear to indicate nonspecific neurolog-
ical immaturity or dysfunction.

3.3 Significant features

The following design features significantly influence what is being measured by a CPT as well as its “hit
rate”:

3.3.1 Stimuli

• Visual and auditory modes

Both need to be studied since there can be problems with auditory and/or visual information process-
ing. Most individuals process visual and auditory information similarly. That is, without a visual or
auditory disorder, they process visual and auditory information similarly in terms of speed, variability,
etc.
However, some individuals process one type of sensory input differently than the other. Thus, the
Visual T.O.V.A. performance may be within normal limits, but the Auditory T.O.V.A. may not be normal
and vice versa. The T.O.V.A. intentionally separates the auditory and visual tests to minimize distrac-
tions and/or stimulation so that specific auditory and visual processing strengths and difficulties can
be identified.

• Non-sequential (“go/no-go” like T.O.V.A.) or sequential

In the typical CPT sequential task, the instructions are to respond whenever an A is followed by a X.
Most CPTs use the A-X format which is cognitively more complex and difficult than the T.O.V.A. that
uses a “go/no go” design with single non-sequential stimuli.

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• Non-language or language based

Non-language based stimuli (like in the T.O.V.A., see Figure 6) minimize the potential confounding of
the results by language, cultural effects, and/or a learning disability.
The Auditory T.O.V.A. uses two single tones. The target is G above middle C (392.0 Hz), and the
non-target is “middle C” (261.6 Hz).

Figure 6: The T.O.V.A. visual stimuli.

• Configuration
Simple stimuli (like in the T.O.V.A.) are easier to process than complex stimuli and have less associa-
tive value.

• Monochromatic vs. multicolored stimuli

Monochromatic stimuli (like in the T.O.V.A.) are simpler and less arousing than multicolored stimuli.
The T.O.V.A. is designed to minimize the number of confounding variables that may affect a person’s
performance.

• Degradation
Although useful in work with schizophrenia, partial degradation of the stimuli are not features of CPTs
used to measure attention.

3.3.2 Presentation of stimuli

• Infrequent and frequent target modes

– The infrequent target mode (or low response demand mode subtest) in quarters 1 and 2 is the
more boring task and is the traditional form for measuring vigilance. Individuals with “low CNS
arousal” tend to do poorly on this form.
– The frequent target mode (or high response demand mode/high inhibition demand mode subtest)
in quarters 3 and 4 is a more stimulating task during which individuals with “high CNS arousal”
can become overstimulated, and individuals with “low CNS arousal” can “wake up”.
– The T.O.V.A. for children 4 and 5 is a shorter test and consists of only quarter 1 (infrequent target
mode subtest) and quarter 3 (frequent target mode subtest) to more appropriately match their
attention span.

• Fixed or variable Inter-Stimulus Interval (ISI)

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A fixed ISI (the interval between the stimuli) minimizes stimulating/alerting changes while a variable
ISI can be more arousing and/or difficult. The T.O.V.A. uses a two-second fixed ISI, which is generally
accepted as the most discriminating interval.

• Reward and/or cost

While these features may be helpful if a CPT was used as a treatment intervention (to train someone
to be more attentive), these features are not commonly used in CPTs.

• Alerting signal
CPTs do not use alerting signals which would make the task easier and increase false negatives.

• Stimulus presentation time

The shorter the time the stimulus is “on”, the more difficult is the task. 100 ms (as in theT.O.V.A.) is
the norm for CPTs.

• Focal point
Focal points (like in the T.O.V.A.) are frequently used in visual CPTs.

3.3.3 Practice vs. novelty effects

The more complex CPTs can have significant practice effects, limiting their use as repeated measures. In
contrast, the T.O.V.A. actually has a small novelty effect—there may be non-significant commission error
changes (increases) in the first half of the second test but not thereafter. Thus, the T.O.V.A. can be repeated
even in the same day.

3.3.4 Length of test and subtests

The longer the test, the harder it is to attend and inhibit. The 21.6 minute test with two 10.8 minute subtests
in the T.O.V.A. are in commercially available CPTs.

For children ages 4 and 5, the T.O.V.A. is 10.8 minutes in length, and the two subtests are each 5.4 minutes
each.

3.3.5 Norms

• The number of subjects per cell

This is a critical factor. In contrast to the T.O.V.A., some CPTs were introduced with insufficient or even
no norms. The Visual T.O.V.A. and Auditory T.O.V.A. were normed with 1714 and 2680 individuals,
respectively. We plan to continue to add additional adult norms to both.

• Sample characteristics

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Unlike the very carefully selected controls with no comorbidity for the T.O.V.A., some other CPTs have
inadequately defined and mixed samples.

• Controlled variables

Age: Since attention variables significantly change from birth to the late teens, year by year norms
are necessary for accurate measurement and comparison.
To illustrate, Figure 7 shows a norm curve of Total Response Time Variability (the first standard devi-
ation of response time) for females.

Figure 7: The response time variability for females in the T.O.V.A. norming study.

For the Visual T.O.V.A. there are year by year norms for each gender from 4-19 and grouped norms
by gender from 20-80+. For the Auditory T.O.V.A. there are year by year norms for each gender from
4-19 and grouped norms by gender from 20-29. The norms for the Visual T.O.V.A. and the Auditory
T.O.V.A. can be found in the T.O.V.A. Professional Manual.

Gender: Since males and females generally have significantly different norms, it is necessary to
have samples of each in the norms.

Intelligence: Intelligence may affect CPT performance and may be an important consideration. Re-
search on this topic is inconclusive.

Test conditions: Time of day and sequencing are important variables that can significantly affect
performance on a CPT. All norms for the T.O.V.A. were obtained in the morning, and the T.O.V.A. was
administered before other testing to avoid excessive fatigue.

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3.3.6 Distractions

Few commercially available CPTs have distractors at this time. It is very difficult to control the novelty
(arousing) effects of so-called distractions which may actually enhance or decrease performance in some
cases. Some people come with their own built-in distractors (foot tapping, talking, chewing gum, etc) that
may act to arouse the person and help them focus. This warrants being noted.

3.3.7 Timing Accuracy of CPTs

The T.O.V.A. Microswitch is used to ensure that the timed responses are measured accurately. Small
variations and inconsistent timing can produce high false positives. To demonstrate why the T.O.V.A. uses
the microswitch, the following comparisons were made:

Software Device Preset Exact Mean Measured Std. Dev Response

Response Time Response Time
(ms) (ms) (ms)

T.O.V.A. Microswitch 300 300 <1

600 599 <1

Conners’ with Mouse 300 353 +28

600 655 +14
900 943 +21

Conners’ with Keyboard 300 355 +28

600 656 +11
900 948 +25

Table 1: T.O.V.A. Microswitch Comparison

Thus, the microswitch in combination with T.O.V.A. software is significantly more accurate than the Conners’
or any of the other CPTs that use the mouse or keyboard and that use more than one computer. (ADHD
Report. 1995:3(6), 7-8).

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4 The T.O.V.A.

4.1 Construction of the T.O.V.A.

The T.O.V.A. consists of two subtests with no transition or warning between them.

In the first half of the test ( the “Infrequent” or vigilance mode), the target appears randomly and infre-
quently with a target : non-target ratio of 1:3.5 The person presses the microswitch infrequently during this
quickly boring half. (There are 36 targets and 126 nontargets per quarter in quarters 1 and 2. Easily bored
(“low arousal”) persons may do poorly during this half.

In the second half of the test (the “Frequent” or high response demand mode) the target appears randomly
and frequently with a target : non-target ratio of 3.5:1. The person is frequently pressing the microswitch
and must inhibit the tendency to respond. (There are 126 targets and 36 nontargets per quarter in quarters
3 and 4.) Easily overstimulated (“high arousal”) persons may do poorly.

Length of each subtest- 10.8 minutes.

For children 4 and 5 years of age – the ratios of targets to non-targets remain the same; however, the
number of stimuli and length are half of those above.

4.2 Sensitivity and Specificity

The sensitivity of a test is its ability to correctly identify true cases (or, for the T.O.V.A. to identify ADHD);
the higher the sensitivity, the fewer false negatives (missing cases of ADHD).

The specificity of a test is its ability to correctly identify individuals who do not have ADHD. The greater the
specificity, the fewer false positives (incorrectly concluding that a person has ADHD).

Since sensitivity and specificity may vary inversely, it is necessary to arbitrarily select a cut-off that best
meets the expected use of the test. For the T.O.V.A., sensitivity and specificity were balanced to obtain
the highest accuracy of both rather than favor one or the other. For instance, we could have selected a
higher sensitivity for the screening version to minimize false negatives; however, the specificity would be
correspondingly lower, and there would be more false positives. Instead of using different cut-offs for the
two versions, they both have the same cut-off.

Of the two common ways to determine sensitivity and specificity, discriminant analysis is the usual and
less conservative one. If dealing with large representative samples from which generalizations about other
samples could be safely made, discriminant analysis would be the acceptable procedure. However, none
of the currently available CPTs, including the T.O.V.A., have large enough samples to use this statistical
method. We feel that it is best to be cautious about generalizing from one sample to others, and we do not
use discriminant analysis in determining sensitivity and specificity. If we did, the results would be:

• Discriminant analysis of T.O.V.A. variables with 29 UADD (ADHD without hyperactivity) cases and
29 matched controls correctly classified 79% of the UADD cases and 90% of subjects without ADHD.
Discriminant analysis of T.O.V.A. variables with 73 ADHD subjects and 73 matched subjects without
ADHD correctly classified 84% and 89%, respectively (see Table 2). ADHD and UADD subjects per-

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formed more slowly and inconsistently and had more errors of omission (inattention) and commission
(impulsivity) than subjects without ADHD. Discriminant analysis of the T.O.V.A. and 10-item Conners’
Parent-Teacher Questionnaire of 61 of the youngsters with ADHD and 61 of the matched subjects
without ADHD correctly classified 87% of subjects without ADHD and 90% of the ADHD subjects with
13% false positives and 10% false negatives. Our sensitivities have been independently validated.
(See Forbes, G. B., Clinical Utility of the Test Of Variables of Attention (TOVA) in the Diagnosis of
Attention-Deficit /Hyperactivity Disorder. Journal of Clinical Psychology, Vol. 54 (4), 1998, 461-476.)

• Receiver Operator Characteristic (ROC) analysis is another way to determine sensitivity and speci-
ficity. ROC analysis is the more conservative technique that is used when it is best to be cautious
about generalizing from one sample to others. Even though to our knowledge the T.O.V.A. is the best
normed CPT, we should be hesitant to assume that the norms from a middle socioeconomic, pre-
dominant culture sample would apply to other samples everywhere even though the growing number
of culturally diverse norms that are appearing in the literature are remarkably consistent. While the
T.O.V.A. norm groups are noteworthy because of the absence of confounding comorbidities, they are
restricted- but perhaps less so than the usual samples of multi-problematic individuals. Accordingly,
the T.O.V.A. uses the more conservative ROC analysis (see Table 3).

Actual group Non-ADHD UADD

Non-UADD* (n = 29) 90%** 10%

UADD* (n = 29) 21% 79%***

Overall Correctly Identified 84%

Non-ADHD (n = 73) 89%** 11%

ADHD ( n = 73) 16% 84%***

Overall Correctly Identified 86%

* UADD = ADD without hyperactivity, ** = specificity, *** = sensitivity

Table 2: Classification By T.O.V.A.– Discriminant Analysis

Receiver Operator Characteristic Analysis

Sensitivity of 0.80 False negatives = 20%

Specificity of 0.80 False positives = 20%
(Cut-off score of 1.8)

Table 3: Sensitivity and Specificity of T.O.V.A. using ROC analysis

Thus, there is an 80% chance that any given T.O.V.A. (with no other information about the individual) will
correctly identify whether the subject has ADHD or not. Of course, with the necessary clinically relevant
data (including behavior ratings and history), the “hit” rate improves significantly to above 90%.

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4.3 Test-Retest Reliability

Temporal stability of the Visual T.O.V.A. was examined in a study of school aged subjects using an interval
of ninety (90) minutes. The subjects were without histories of learning disabilities, psychiatric (including
ADHD) disorders, neurological disorders, or medical disease, and not on any medications.

The 24 subjects (15 males, 9 females) had a mean age of 8.31 years (SD = 2.35). Each subject received
an initial T.O.V.A. and was re-administered the second T.O.V.A. ninety minutes after completing the initial
test. Each subject completed both tests by 1 p.m. on the same day.

Data analysis yielded no significant differences within the group between the two tests (Table 2).

T.O.V.A. ® TEST RETEST p Correlation

Total Score Mean SS Mean SD Coefficient

Omission Errors (#) 18.54 20.41 25.42 28.84 .063 .80

Commission Errors (#) 30.50 19.98 31.33 22.49 .773 .78
Response Time (ms) 539.66 110.56 530.85 111.50 .992 .93
Variability (ms) 202.46 65.07 279.87 95.27 .175 .77

Table 4: Table of Means, SD, t values and Correlations for Test / Retest Scores

The Visual T.O.V.A. demonstrated temporal stability over a ninety minute episode. The ninety minute test
interval was selected because many clinicians use the T.O.V.A. as a tool to determine the effects of stimulant
medications by comparing a baseline (no medication) test and an on-medication test 90 minutes later.

Another test-retest study with 33 randomly selected non-ADHD children, 40 children with ADHD, and 24
non-ADHD adults also revealed no significant differences in the T.O.V.A. variables, using paired t-tests.

4.4 T.O.V.A. Formulas

Formulas and algorithms for calculating the all T.O.V.A. variables can be found in the T.O.V.A. Professional
Manual.

4.5 Screening Version

The Screening Version of the T.O.V.A. is used by schools, other educational settings (including learning
centers), and non-licensed health care professionals. Uses of the Screening Version include:

• Measuring attention in persons without an attention disorder to determine:

– attention assets and liabilities
– baseline functioning in individuals (such as athletes and military personnel) at risk for injury

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T.O.V.A. Clinical Manual 4 THE T.O.V.A.

• Screening children and adults for attention problems

The Screening Version is the same test as the Clinical Version; however, the printouts are formatted dif-
ferently to reflect that they are used for screening rather than as part of a clinical assessment or treatment
monitoring process.

The Screening Version Summary states that it is used for screening purposes only, not for clinical assess-
ments. The results are or are not within normal limits, and if not within normal limits, a referral to a clinician
is warranted. Contact the T.O.V.A. Referral Service and telephone number, 1-800-REF-TOVA (733-8682)
for referrals to clinicians specializing in attentional disorders in that area.

The Screening Version includes the Individualized Success Strategies-School and Home

4.6 Clinical Version

The Clinical Version of the T.O.V.A. is used by licensed clinicians and researchers.

The Clinical Form analyzes the Raw Data and includes the Individualized Success Strategies-School and
Home.

Uses of the Clinical Version include:

• Measuring attention in persons without an attention disorder to:

– determine attentional assets and liabilities
– establish baseline functioning in individuals at risk for injury (due to head injuries from acci-
dents, sports, military service) or CNS disorders

• Measuring attention in individuals being evaluated for an attention disorder, including ADHD and
Traumatic Brain Injury

• Measuring attention in other disorders affecting the brain, including AIDS and dementia

• Measuring effects of nonmedical treatment interventions, including Neurofeedback

• Measuring medication effects using a challenge dose of a stimulant medication

• Helps to document the optimal dosage of medication

• Monitors the course of attention problems and treatment over time

4.7 Administering the T.O.V.A.

Training of both professionals and nonprofessionals to administer and monitor the test should follow the

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T.O.V.A. Clinical Manual 4 THE T.O.V.A.

general outline of the instructions in the Professional Manual and include the use of the T.O.V.A. ® Rating
Form for recording observations that may be helpful to the clinician. In general, we want the subject to
balance speed and errors—to be as fast as they can be, yet to minimize errors. (See Appendix A for Testing
instructions.)

The T.O.V.A. should be administered in the morning to comply with the norming procedure and to min-
imize diurnal variability which can significantly affect test performance. (When comparing two tests it is
especially important that they have been given at the similar time of day (that is, both in the morning or, if
necessary, the afternoon.) If the T.O.V.A. is part of a battery of tests, it is important to administer it first—
before the subject is fatigued or bored. If both the auditory and visual T.O.V.A. are to be administered, a
sufficient time (>1.5 hours) should elapse between the tests to enable the subject to rest.

The norms were obtained with an observer present at all times in the room with the subject. Research
has shown that the observer’s presence makes a significant difference even though they are not interacting
with the subject. Test performances by children and adults can be significantly worse when the observer is
not present.

When testing for the first time, the practice test should be given in its entirety. For subsequent testing, only
a portion of the practice test may be necessary to remember the task.

Although prompting is helpful in the practice test, it is not used during the actual testing unless absolutely
necessary since prompting was not given for the norms.

The T.O.V.A. ® Rating Form (Appendix A) can be used to record observations during testing. This form is
not copyrighted so that it can be duplicated and used as needed.

4.7.1 Pre-test Preparation

Preparing the subject is crucial, because it assures that the test is administered properly and replicates the
same conditions as the T.O.V.A. norms.

1. Prior to testing, explain to the subject (or to caregivers) that no caffeinated beverages (e.g. coffee, tea,
cocoa, or soft drinks) should be ingested on the day of a test. Nor should the subject have smoked.

2. Time of Day: Testing is best done between 6 AM and 1 PM to control any diurnal effects.

3. Setting: Testing should be done in a quiet, darkened room with a glare-free monitor screen. Clocks
should not be visible or audible. It is best if the subject faces a neutral colored wall without distracting
pictures. The monitor should be placed so that the keyboard is not visible or available to the subject.

4. At test time:
• Introduce yourself to the subject.
• Ask if the subject needs to use the bathroom.
• Determine whether they have glasses or hearing aid if needed.
• Have subject remove his or her watch.
• Determine from subject or caregiver any medications taken in the last 12 hours (Ritalin, anticon-

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T.O.V.A. Clinical Manual 4 THE T.O.V.A.

vulsants, and/or antihistamines). Add these, with dosage and interval since administered, in the
New Test Session window.
• Position the subject and chair so he or she may sit with feet on the floor.
• Position the monitor so the screen is at or near eye level.

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T.O.V.A. Clinical Manual 5 FACTORS AFFECTING T.O.V.A. PERFORMANCE

Part II

Interpreting the T.O.V.A.

The clinician determines the application of the T.O.V.A. in measurement, tracking, assessment and treat-
ment. Familiarity with the scientific basis of the T.O.V.A. as well as the interpretation of the T.O.V.A. report
will help establish the best use of the T.O.V.A. Thousands of clinicians have used the T.O.V.A. for a variety
of purposes that call for the objective measurement of variables of attention. The following information is
based on both the readout of the reports and the clinical work of the authors. Clinical casework or reflec-
tions are chosen to illustrate the authors’ use of the T.O.V.A. and are not a recommendation for assessment
or treatment.

5 Factors Affecting T.O.V.A. Performance

The T.O.V.A. performance can be significantly improved or worsened by anything that affects attention:

• Someone with ADHD could successfully self-medicate with nicotine and/or caffeinated beverages,
assuming that excessive quantities are not ingested. A person with ADHD who has coffee, an energy
drink, or cigarettes before testing may very well perform within normal limits on the T.O.V.A.

• On the other hand, acute caffeine and nicotine withdrawal can have adverse effect on attention. Thus,
a person without ADHD can do poorly on the T.O.V.A. if they do not indulge in their habitual two or
more cups of coffee in the morning.

• Any medication that can affect brain function can affect attention. Someone taking antihistamines for
allergies can become sufficiently sedated so that the T.O.V.A. performance may not be within normal
limits just as someone receiving lithium for a bipolar disorder may have slow response times.

• People with ADHD who have extensive video game experience and highly trained athletes, etc. may
perform normally on the visual T.O.V.A. due to the eye-hand training. The auditory T.O.V.A. is useful
in these situations although musicians may do better on the auditory T.O.V.A. than others.

• Sleep deprivation, anxiety, and depression, as well as a number of psychiatric conditions, can ad-
versely affect performance whether comorbid with ADHD or not.

• Although the literature is not definitive, a person with an above average intelligence may perform
better than average. Conversely, someone with a lower than average intelligence may perform less
than average.

It is important that the clinician obtain an adequate history to be able to interpret T.O.V.A. results,
taking these factors into account.

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T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

6 The T.O.V.A. Report

The T.O.V.A. Interpretation Report

The following pages contain a Clinical T.O.V.A. Interpretation Report and discussion of the forms and find-
ings. Some of the forms are designed for use by researchers and some by advanced T.O.V.A. users. When
printing out a Report, you may select which pages you want printed and not print out the other pages. When
sending a Report to a non-clinical setting such as a school, we recommend sending only the Introduction
and the Summary forms. When sending a Report to a clinician, we recommend sending the Introduction,
Summary, Analyzed Data, Analyzed Data Page, Tabulated Data, and Raw Data Graphs.

Introduction

This page provides basic information about the T.O.V.A. and its uses.

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T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

Summary

This page and pages to follow include Demographic data about the subject—ID number, subject’s name,
gender, and age—as well as general session information—visual or auditory, version #, serial #, date and
time of administration.

• Comments: relevant comments about the session may be entered here.

For the sample protocol:
Baseline.

• T.O.V.A. Interpretation: summarizes the results by comparing the subject’s performance with indi-
viduals who do not have an attention problem and with individuals who have been independently
diagnosed with ADHD, matched for age and gender.
The interpretation statement will be one of the following:
– If the performance and the Attention Performance Index (API) are within normal limits:
The results of this T.O.V.A. test are within normal limits.
– If the performance is not within normal limits but the API is within normal limits, the sentence will
be:
The results of this T.O.V.A. test are not within normal limits and are suggestive of an
attention problem.
– If the performance and the API are not within normal limits, the sentence will be:
The results of this T.O.V.A. test are not within normal limits and are suggestive of an
attention problem, including ADHD.
– If the performance is within normal limits but the API is not within normal limits, the sentence will
be:
Although the results of this T.O.V.A. test are within normal limits, based on the pattern
of performance there is some evidence of a possible attention problem, including ADHD
(see the Attention Performance Index score).
Note: “Suggestive of an attention problem” does not mean that the person has ADHD, but
only that the results were not within normal limits.
Since the performance and the API were not within normal limits in the sample protocol, the
Interpretation is:
The results of this T.O.V.A. test are not within normal limits and are suggestive of an
attention problem, including ADHD.

• Session and Response Validity summarizes whether there were any occurrences that might in-
validate or effect the results, such as user interruptions, excessive errors, or the testing was not
administered in the morning.
When one or more quarters are labeled “invalid”, and the remaining quarters are within normal limits,
the protocol would be interpreted as within normal limits. When this happens, a statement is made
that the invalid quarter(s) may have been the result of an attention disorder, and that the printed
interpretation and results should be viewed cautiously.
Validity Measures
– Tests obtained after 1 PM must be interpreted cautiously since all of the norms were obtained

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T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

between 6 AM and 1 PM and because of possible diurnal effects on attention.

Note: Repeated tests for the same person (e.g. at different ages, and before and with
treatment) can be compared if administered approximately the same time of day.
– User interrupts: The tester can interrupt the test and restart it at the same place if necessary.
However, the remainder of an interrupted test must be cautiously interpreted since the norms
would not strictly apply.
– Excessive Omission Errors (≥90%/quarter) These errors invalidate the quarter since there are
too few responses to be a sufficient sample. Generally, it means that the subject stopped re-
sponding or, rarely, that the hardware malfunctioned.
– Response Times = 0 ms: If there are no recorded correct responses, that quarter would be
considered invalid.
– Excessive Anticipatory Responses (≥10%/quarter of responses were <150 ms) Quarters with ex-
cessive Anticipatory Responses (that are usually guesses) must be interpreted cautiously since
most people do not process and respond correctly to information that quickly. Excessive guess-
ing, a common finding in persons with attention problems, tends to increase Response Time
Variability and Commission Errors, and to decrease Response Time and Omission Errors.
However, a small number of people (especially athletes and computer game players) can re-
spond correctly faster than 150 ms. To determine whether someone was guessing or processing
information and correctly responding faster than most people, compare Nontarget to Target ratios
found on the Tabulated Data Page. If the ratio of Anticipatory Responses for targets to nontargets
is greater than 2:3.5 (>0.57) in quarters 1 or 2 or smaller than 4:1 (<4) in quarters 3 or 4, the
individual did better than chance, and the quarter is valid.
– Excessive Commission Errors may affect the other variables in that quarter since rapid and addi-
tional responses tend to decrease Omission Errors and Response Time and increase Variability.
Interpret these quarters cautiously.

T.O.V.A. ® (Visual)
Age Quarters 1 or 2 Quarters 3 or 4

4-5 ≥20% ≥70%

6-12 ≥10% ≥60%
13+ ≥10% ≥50%

T.O.V.A. ® (Auditory)

6-7 ≥20% ≥60%

8-12 ≥10% ≥60%
13+ ≥10% ≥50%

Table 5: Excessive Commission Errors Alert

For this sample protocol–

The test was completed with no interruptions or excessive errors, and administered at
the appropriate time of day (6:00am-1:00pm), matching the conditions of the T.O.V.A.
normative studies.

• Symptom Exaggeration Index (SEI) is a measure of symptom exaggeration or “faking bad”. The
SEI is only applicable for ages 17 and older and relevant when the overall performance is not within

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T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

normal limits, and the possibility of secondary gain exists.

The SEI criteria (1 point each) are:

– Either Total Omission or Commission Errors Standard Scores <40

– Total Response Time Variability > 180 ms
– Half 2 Response Time > Half 2 Post-Commission Response Time
– Half 2 Commission Error Response Time > Half 2 Response Time

There are four levels of the SEI:

– If the SEI score is 0 or 1, the SEI report is:
Based on the subject’s pattern of performance, there is no evidence of symptom exag-
geration.
– If the SEI score is 2, the SEI report is:
CAUTION: Based on the subject’s pattern of performance, there is some evidence of
possible symptom exaggeration. If the potential exists for secondary gain, a deliberate
effort to exaggerate symptoms should be considered.
– If the SEI score is 3, the SEI report is:
CAUTION: Based on the subject’s pattern of performance, there is strong evidence of
possible symptom exaggeration. If the potential exists for secondary gain, a deliberate
effort to exaggerate symptoms should be considered.
– If the SEI score is 4, the SEI report would be
CAUTION: Based on the subject’s pattern of performance, there is very strong evidence
of possible symptom exaggeration. If the potential exists for secondary gain, a deliberate
effort to exaggerate symptoms should be considered.
– For the sample protocol with a SEI of 0
This was a valid administration of the T.O.V.A., and the subject appears to have been
compliant with the instructions and demonstrated adequate effort.

• Treatment: Current treatments, including any prescribed or over the counter medications (with dosages
and medication-test interval), if any, are recorded.
Note: The clinician will need to determine what effects the treatment may have on the T.O.V.A.
performance. For the sample protocol:
None was entered.

• Comparison to the Normative Sample:

– The first statement summarizes whether the overall performance (the T.O.V.A. Interpretation)
was or was not within normal limits. For the sample protocol:
The overall performance was not within normal limits.
– The next statements summarize which variables, if any, were not within normal limits.
For the sample protocol:
Inconsistency (Response Time Variability) was borderline in Q1 & Q2 and not within
normal limits in Q3 & Q4. This finding is important since inconsistency is the most
sensitive measure in the T.O.V.A. Impulsivity (Commission Errors) was not within normal

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T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

limits in Q3.
Comment: Note that when Response Time slows the most in quarter 4, Commission Errors
significantly improve.
– Bar graphs
The quarter by quarter standard scores for the four primary variables are illustrated.
Standard scores above 110 are above average.
Standard scores between 85-110 are average.
Standard scores 80-85 are borderline.
Standard scores below 80 are not within normal limits.
If the standard score is below the limit of the vertical axis (<40), it would be noted as a downward
facing red triangle.
If the standard score is above the limit of the vertical axis (>120), it would be noted as an upward
facing red triangle.

• Attention Performance Index

A negative API score indicates that the T.O.V.A. performance was similar to a pattern characteristic of
someone independently diagnosed with ADHD. However, a negative score does not make a diagnosis
of ADHD, and a person with ADHD can have a score within normal limits.
For the sample protocol:
The API score of -0.39 is characteristic of someone diagnosed with ADHD.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
83 83 71 63 116 106 105 92 85 89 78 104 100 100 100 100
T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

Analyzed Data

• Comparison to the Normative Sample

After a brief description of the use of standard scores and standard deviations, the table contains the
analyzed data, organized by quarters, halves, and total results.

– Codes used in this table are:

* [ ] (score in brackets) means that the quarter may not be valid and must be interpreted
cautiously.

* ! ! (score between two exclamation points) means that there were excessive Commission
Errors in that quarter. Quarters with excessive Commission Errors need to be interpreted
cautiously since Response Time Variability can be artificially increased, and Response Time
and Omission Errors can be.

* * (score flagged with an asterisk) means that the results are valid, not within normal limits,
and compatible with an attention disorder.

* ‘b’ means that the results are valid and borderline.

For the sample protocol:
This protocol has a number of quarters with * and a few with b.
– Interpreting the Analysis Table
For the sample protocol:
Variability and Commission Errors are not within normal limits and are suggestive of an
attention disorder.

• Attention Performance Index (see discussion above for the Summary)

A brief description of the API is followed by the criteria and data.
For the sample protocol:
The ATI score of -0.39 is characteristic of someone diagnosed with ADHD.
Note that this finding does not make the diagnosis of ADHD. The clinician needs to consider
additional sources of information, including the history, behavior ratings, and the comparison
to the normative sample.

• Symptom Exaggeration Index (see discussion above for the Summary)

A brief description of the SEI is followed by the criteria and scores.
For the sample protocol:
This was a valid administration of the T.O.V.A., and the subject appears to have been com-
pliant with the instructions and demonstrated adequate effort.

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T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

Analyzed Data (Graphs)

• The Graphs present T.O.V.A. results using standard scores. If the standard score is below the limit of
the vertical axis (<40), it would be noted as a downward facing red triangle.
The “X” axis of the graph will be moved (up or down) automatically as necessary to allow sufficient
room for the results. If the standard score is above the limit of the vertical axis (>120), it would be
noted as an upward facing red triangle.
The results of four tests can be displayed side-by-side to compare performances over time or no
treatment and treatment. See the User’s Manual for details on how to compare tests.

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 RT Variability Response Time
120 120

110 110

100 100
Standard Score

90 90

80 80

70 70

60 60

50 50

40 40

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
83 83 71 63 116 106 105 92

Commission Errors Omission Errors

120 120

110 110

100 100
Standard Score

90 90

80 80

70 70

60 60

50 50

40 40

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
85 89 78 104 100 100 100 100
T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

Tabulated Data

As noted Tabulated Data is provided for researchers and advanced T.O.V.A. users.

• Comments, if any.
Data are listed by quarters, halves and total, and include:
– RT Variability (ms)
– Response Time (ms)
– Post-Commission Responses (#, Response Time in ms, and Variability in ms)
– D Prime1 (Standard Score and Raw Score)
– Commission Errors (# and %, ), Response Time (ms)
– Omission Errors (# and %)
– Anticipatory Responses (To Nontargets- # and To Targets- #)
– Multiple Responses #
– Total Correct # (Correct Responses # Correct Nonresponses #)
– Beta1
– User Interrupts #
– Hardware Errors #

• Session Parameters
– Standard configurations:
Infrequent = quarters with infrequent targets
Frequent = quarters with frequent targets
IIFF for ages 6- to 80+ (Standard or form 1 with 4 quarters, 21.6 minutes)
or
IF for ages 4 and 5 (form 2 with 2 quarters, 10.8 minutes)
– Inter-Stimulus Interval (time between successive stimuli): 2000 ms
– On-Time (time when the stimulus appears in a 2000 ms period): 200 ms
– Off-Time (time when the stimulus disappears in a 2000 ms period): 300 ms
– Anticipatory Cutoff: If a response (microswitch press) occurs within 150 ms of On-Time (200 ms),
the response is considered an Anticipatory (usually a guess or impulsive response)
Note: Research configurations may be altered as needed

• Import file identification number and import date (if applicable)

For the sample protocol:

No tester identification*, designation of test, or comments were recorded. Test Format was
#1 (IIFF with the standard timing). The test (version 7.2) was administered on May 31, 2005
and reformatted in version 8.0 on July 23, 2010.
* The tester identification was removed for the sample protocol.

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 1 Beta and D prime are part of the Receiver Operator Characteristics (ROC) analysis, and are not used in the T.O.V.A. Interpretation.

They are included for researchers.

T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

Raw Data (Graphs)

All of the subject’s responses are sequentially displayed.

Codes:

•  = Correct responses and correct non-responses (black square)

• × = Omission, Commission, and Anticipatory Errors (red ‘X’)

• • = Post-Commission Error Responses (green dot)

• Light gray area = Responses within normal limits for age and gender.

• Commission errors and post-commission responses are linked by lines:

– A positive slope ( / ) of a light gray line identifies a usual response (slowing down) after a com-
mission error. (The person recognizes the mistake and slows down.)
– A negative slope ( \ ) of a black line identifies an unusual response (speeding up) after a com-
mission error. (The person doesn’t recognize the error, is impulsive, and/or doesn’t care.)
– Omission errors are underscored (_) in red. Strings of 3 or more omission errors are unusual,
and may be caused by a neurological condition (such as narcolepsy or a seizure disorder),
oppositional behavior, or, rarely, a hardware error.

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 1,050
900
Milliseconds

750
600
Q1 450
300
150
0
-150
0 40 80 120 160
Trial #
1,050
900
Milliseconds

750
600
Q2 450
300
150
0
-150
0 40 80 120 160
Trial #
1,050
900
Milliseconds

750
600
Q3 450
300
150
0
-150
0 40 80 120 160
Trial #
1,050
900
Milliseconds

750
600
Q4 450
300
150
0
-150
0 40 80 120 160
Trial #
T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

Raw Data (Tables)

In addition to the identifying information, these tables present the sequence of targets and non-targets, and
the subject’s response to each one. Errors are shown in red, and response times are in ms. A negative
response time indicates a response that was made before the stimulus appeared.

The codes are:

T = target N = nontarget TO = Omission Error

NC = Commission Error TA = Anticipatory Response M = Multiple Responses
Red = Error Responses Green = Post-Commission Error Response
* = User or Hardware Interrupt

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T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

Error Graphs

This error descent graph displays the number of Commission, Omission, and Anticipatory Errors and norms
by quarter and total errors (the red line). The gray area represents the norm (standard score of 100) for age
and gender. The light gray line represents a standard score of 85, and the black line represents a standard
score of 80. We are in the process of determining the clinical usefulness of this display.

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 Commission Errors Omission Errors
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
650 650

625 625
Correct Responses

Correct Responses
600 600

575 575

550 550

525 525

500 500

Anticipatory Responses All Errors

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
650 650

625 625
Correct Responses

Correct Responses

600 600

575 575

550 550

525 525

500 500
T.O.V.A. Clinical Manual 6 THE T.O.V.A. REPORT

Reaction Time Histogram

This histogram is included for researchers and advanced T.O.V.A. users. We are examining new mod-
els of Reaction Time that may make the T.O.V.A. even more accurate and helpful for clinicians and re-
searchers. We have been using the traditional Gaussian distributions (“bell curves”) to model Reaction
Time histograms. We are now exploring a new model, the “ExGaussian” distribution with its unique mea-
sure, Tau.

Gaussian and ex-Gaussian models are very similar, except for Tau. The ex-Gaussian Mu corresponds to
the Gaussian Mu (the average response time), and ExGaussian Sigma corresponds to the Gaussian Sigma
(variability or width of the curve). The new parameter, Tau, models an exponential decay of the Reaction
Time histogram to the “right” (longer reaction times). Normally Tau is very small; however, recent research
indicates that Tau may be a more sensitive parameter defining attention deficits than either Mu or Sigma
alone. Our hypothesis is that although Mu and Sigma may be within normal limits, a significantly skewed
Tau may be indicative of ADHD.

Codes:

Gray = Correct Responses Light Gray = Norm Red = Commission Errors

Blue = Post-Commission —– = ExGaussian

The ms for Mu, Sigma, and Tau are listed by quarters, halves, and total in the table.

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 Reaction Time Histogram
85

80

75

70

65

60
Number of responses

55

50

45

40

35

30

25

20

15

10

0
0 250 500 750 1,000 1,250 1,500 1,750
Reaction time (ms)

ExGaussian fit Post-commission Commission Errors Correct Responses Norm

T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

7 Individualized Success Strategies: School

These strategies are designed for individuals who need support in their school environment. Whether the
person has an attention problem, demonstrates behavior problems, or just needs more structure to succeed,
these strategies focus on creating successful habits and developing successful structure in the classroom
and school environment. Interpreting a student’s T.O.V.A. results along with interviews and behavior ratings
can help determine the most appropriate strategies for the individual. We recommend coordinating the
school and home strategies for the student to maintain consistency and minimize the possibility of overload.
Available by clicking on the Help button on the main T.O.V.A. Screen, these strategies are also an entry into
dialogue with teachers and school staff.

8 Individualized Success Strategies: Home

These strategies are designed for individuals who need support in their home environment. These may be
used for children, adolescents and adults. Depending upon the person’s age, they may also be adapted
to be utilized in the workplace if needed. If the individual is in school, we recommend coordinating the
home and school strategies to ensure consistency in the approach to success. Whether the person has
an attention problem, demonstrates behavior problems, or just needs more structure to succeed, these
strategies focus on creating successful habits and developing successful structure in the home environment.
Interpreting a person’s T.O.V.A. results along with interviews and behavior ratings can help determine the
most appropriate strategies for the individual.

9 T.O.V.A. ® Protocols

Reading and understanding the T.O.V.A. in the context of the a clinical evaluation or in establishing a base-
line for attention requires an understanding of the relationship between the variables and the quarters, as
well as the meaning of the API and the SEI and their link to the Comparative to the Normative Sample
standard scores. When first reading a T.O.V.A. follow the standard scores for each variable from quarter
to quarter. Look for scores below 85 to indicate difficulty with consistency, processing speed, impulsivity
or attention. Note decreases or increases between quarters and halves. Pay attention to the relationship
between certain variables. For instance, is the person fast but makes a lot of errors, or are they slow and
make few errors? Is the person inconsistent in the first half (low arousal) but fast, consistent and accurate
in the second half (high arousal). This can tell you something about the person and the person’s test taking
strategy. One can extrapolate from this to how the person may behave, but it is important to ask the subject
if your “story” fits. Often it will if you follow the inferences that one can deduce from the T.O.V.A.

Experienced T.O.V.A. users consult the Tabulated Data, the Error Graph and the Raw Data Graphs pages
on a regular basis to gain more insight into the subject’s performance on the T.O.V.A., and the Raw Data
Tables when necessary. Each of these pages give more data that help “tell the story” of the subject.
Along with the four variables, the T.O.V.A. also provides information on vigilance over the 21.6 minutes,
adaptability (changes from half 1 to half 2), and neurological status (consecutive omissions and excessive
multiple responses). Gathering all this data together helps form a picture of the person’s performance
on the T.O.V.A. which can be useful in understanding the person and in designing appropriate treatment
interventions or protocols.

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T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

The API is not a read alone score. It should always be analyzed in relationship to the Comparison to the
Normative Score. The API score is a comparison of the person’s scores based on selected measures that
persons with an independent diagnosis of ADHD frequently demonstrated. Primarily focused on variability,
response time and d’ prime (degradation of performance over time), the API score is an adjunct to the Com-
parison to the Normative Sample. It provides research-based information and can be used as additional
information in understanding the subject’s performance and when comparing tests pre- and post-treatment
to determine one aspect of the success of treatment.

The SEI is a research based measure determined by the results of persons who “faked bad” on the T.O.V.A.
If the SEI score indicates the possibility of malingering and secondary gain is a concern, consider the
possibility of “faking bad”, or other reasons that a person may have triggered a high score on the SEI,
such as drug use, psychiatric conditions, oppositional behavior and/or very severe problems with attention.
The SEI scores are consistent with people who fake bad on the test; however, some persons with severe
attention problems may trigger the SEI. The SEI is meant to alert the clinician to the possibility of “faking
bad” and to provide a window for consideration of secondary motivation as well as for conversation with the
subject concerning their test results.

Though two T.O.V.A.’s may look similar, remember that no two people are the same. Always understand
the T.O.V.A. in the context of the person, and the person in the context of the T.O.V.A. results. Good clinical
practice makes use of the T.O.V.A. in interpreting the person, but relies on a complete assessment of the
person to determine diagnosis and treatment decisions.

The protocols below are presented and reviewed to illustrate the T.O.V.A. s and their uses.

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T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

Clinical Protocol #1

This 41-year-old male has been in psychotherapy off and on for 7 years due to relational issues. Gradually,
the therapist learns that he frequently doesn’t keep commitments, avoids paper work, accounting, decision
making, and doesn’t pay attention to tasks that require sustained attention. He frequently forgets appoint-
ments and feels overwhelmed. No history of learning disabilities or psychiatric diagnoses. He recently
reported that he had a head injury in a motorcycle accident 20 years ago when he was unconscious for
unknown amount of time.

First Visual T.O.V.A. Summary: Baseline

T.O.V.A. Interpretation: The results of this T.O.V.A. test are not within normal limits, and suggest the
presence of an attention disorder, including ADHD.

Session and Response Validity: Acceptable

Symptom Exaggeration Index: 0 (no evidence of exaggeration)

Treatment: None recorded

Comparison to the Normative Score: Good Response Time Variability (RTV) in low arousal condition
(Quarters 1 and 2). However, the standard score drops 8 points in the change to high arousal (Quarter 3)
and drops to 66 (not within normal limits) in Quarter 4. Response Time (RT) drops 8 points from Quarter
2 to Quarter 3 and then another 19 points to 89 in Quarter 4. Commission Errors are within normal limits.
Omission Errors drop to 56 (not within normal limits) in Quarter 3 and improve to 100 in Quarter 4. Overall,
the scores suggest difficulty with transition and adaptability (RTV, RT and Omissions drop in Quarter 3) and
tiring after 15 minutes (RTV and RT drop in Quarter 4).

Attention Performance Index score is 0.57 (within normal range). Comments: He was referred to his
personal physician with a preliminary diagnosis of Traumatic Brain Injury.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
>120 >120 112 66 115 >120 108 89 110 105 102 107 100 100 56 100
T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

Second Visual T.O.V.A.: On 20 mg Methylphenidate SR

Note: The baseline (no medication) T.O.V.A. is in the previous section.

T.O.V.A. Interpretation: The results of this T.O.V.A. are within normal limits.

Symptom Exaggeration Index: 0

Session and Response Validity: Acceptable.

Treatment: 20 mg. of Methylphenidate SR taken 2.2 hours before testing

Comparison to the Normative Sample: All 4 Quarters are within normal limits.

Comments: T.O.V.A. and behavior ratings are within normal limits. Good response to medication.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
>120 >120 118 116 107 109 104 104 110 105 120 116 100 100 101 100
T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

Clinical Protocol #2

This 17-year-old female was referred because of academic difficulties. She reported being frequently bored,
daydreaming excessively and feeling mildly depressed.

T.O.V.A. Interpretation: The results of this test are not within normal limits, and suggest the presence of
an attention problem, including ADHD.

Session and Response Validity: Acceptable

Symptom Exaggeration Index: 0 (no evidence of symptom exaggeration)

Treatment: none recorded (baseline T.O.V.A.)

Comparison to the Normative Sample: The overall results are not within normal limits. Inconsistency
(Response Time Variability) was not within normal limits in Quarters 1 and 2 and was borderline in Quarter
3. This finding is important since RTV is the most sensitive measure of the T.O.V.A. Interestingly, her RTV
scores progressively improved throughout the test, so that by the end (Quarter 4) her RTV score was within
normal limits.

Attention Performance Index: 1.36 (within normal limits) Comments: Based on history, behavior ratings
and T.O.V.A. scores, she was referred to her physician who prescribed medication and requested an on-
medication T.O.V.A. The 18-year-old female (case # 2) was administered the T.O.V.A. on trial medication.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
71 76 85 97 96 104 102 120 109 108 111 103 101 102 106 104
T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

Second Visual T.O.V.A. FOR CASE #2: On 5 mg Adderall

T.O.V.A. Interpretation: The results of the T.O.V.A. are borderline, and may suggest an attention problem,
including ADHD.

Session and Response Validity: Acceptable

Treatment: 5 mg Adderall taken 1.5 hours before taking medication.

Comparison to the Normative Sample: The overall performance was borderline. Impulsivity was border-
line in Quarter 4. RTV and RT improved from baseline T.O.V.A.; however, Commission Errors were worse
as were Quarter 4 Omissions.

Attention Performance Index: 3.63 (unremarkable and better than baseline) Comments: The on-medication
results are mixed (some variables better and some worse) when compared with baseline T.O.V.A. API score
is much improved; however, this doesn’t take into account the borderline impulsivity score. Overall, mixed
results are usually indicative of excessive medication and that a lower dosage may produce better results.
See below.

Based on self-report and the mixed T.O.V.A. results with 5 mg of Adderall, the 18-year-old female (case #
2) was retested on a lower dosage of medication.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
108 115 116 110 >120 >120 >120 >120 94 93 101 83 101 102 106 88
T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

Third Visual T.O.V.A.: On 2.5 mg of Adderall

T.O.V.A. Interpretation: The results of this T.O.V.A. test are within normal limits.

Session and Response Validity: Acceptable

Symptom Exaggeration Index: 0 (no evidence of exaggerated symptoms)

Treatment: 2.5 mg. of Adderall taken 1.5 hours before testing..

Comparison to the Normative Sample: All quarters are within normal limits and as good or better than
baseline scores.

Attention Performance Index: 5.12 (better than baseline and with 5 mg of Adderall)

Comments: Good response to 2.5 mg of Adderall. API continues to improve and all quarters are within
normal limits.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
111 105 110 120 115 113 109 116 109 108 111 116 101 102 106 104
T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

Clinical Protocol #3

History: This boy, almost 11 years old, was referred for psychotherapy due to impulsive behaviors, dis-
tractibility, lack of focus, difficulty with follow through and arguing with his parents. He had a previous
diagnosis of ADHD, combined type, and was on medication at the beginning of treatment. At the time of the
referral the physician was considering raising his medication to obtain better clinical results.

T.O.V.A. Interpretation: The results of this T.O.V.A. are not within normal limits, and the overall pattern of
performance is suggestive of an attention problem, including ADHD.

Session and Response Validity: There are excessive >10% Anticipatory Errors in Quarters 3 and 4 (21%
and 26.5%, respectively). Since excessive ARs tend to increase Commissions and decrease Omissions,
the results need to be interpreted cautiously.

Symptom Exaggeration Index: Not available for a person under 17 years of age.

Treatment: None (baseline).

Comparative to the Normative Sample: The overall performance was not within normal limits. Response
Time Variability was borderline in Quarter 1 and not within normal limits in Quarters 2 and 4. This is
important as it is the most sensitive measure of the T.O.V.A. Response Time was not within normal limits in
Quarter 4. Impulsivity (Commission Errors) was not within normal limits in Quarters 1 and 2 and inattention
(Omission Errors) was not within normal limits in Quarter 4. There were 25 multiple responses in Quarter
4. Note that in Quarter 3, all variables were within normal limits. It may be that the increased arousal in
Half 2 improved performance, but after 5 minutes, he began to tire inQuarter 4 (increased Response Time
Variability, Omissions and Multiple Responses.).

API: -5.61 (compatible with a pattern commonly seen in persons diagnosed with ADHD)

Case #3: T.O.V.A. test to compare his baseline T.O.V.A. to his medication scores.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
80 79 96 <40 87 89 108 66 70 61 96 89 98 94 98 <40
T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

Second Visual T.O.V.A. for Case #3: On 50 mg Adderall XR

T.O.V.A. Interpretation: The results of this test are not within normal limits, and are suggestive of an
attention disorder, including ADHD.

Session and Response Validity: Acceptable

Treatment: 50 mg Adderall XR taken 2.5 hours before taking the test.

Comparison to the Normative Sample: This test is not within normal limits. Impulsivity (Commission
Errors) was borderline in Quarter 2 and not within normal limits in Quarters 1 and 4.

Attention Performance Index: 1.27 (not compatible with a pattern commonly seen in persons diagnosed
with ADHD) Comments: The API score is much improved in comparison to the baseline. However, some
variables are now worse on medication than when off medication. Impulsivity is now worse and this is one
of the behaviors that the subject exhibits. Mixed results suggest a lower dosage of medication may work
better for this subject.

Case #3: Test to compare his baseline T.O.V.A. to his 50 mg Adderall XR T.O.V.A. score and his 10mg
Adderall XR T.O.V.A. score.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
92 106 87 117 110 109 114 118 74 84 94 76 98 105 96 106
T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

Third Visual T.O.V.A.: On 10 mg of Adderall XR

T.O.V.A. Interpretation: The results of this test are within normal limits.

Session and Response Validity: Acceptable

Treatment: Challenge dose of 10mg of Adderall XR taken 2.5 hours before testing.

Comparative to the Normative Sample: Overall performance is within normal limits.

Attention Performance Index: 3.37 (better than baseline and with 50 mg of Adderall XR) Comments: All
scores are within normal limits. The API is higher than in both previous tests. Impulsivity scores are very
good. The dosage was decreased to 10 mg of Adderall XR rather than raising dosage from 50 mg.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
107 113 113 116 109 105 102 102 115 112 120 >120 104 94 100 93
T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

Clinical Protocol #4

History: This 9-year-old girl was tested because of inattention and verbal impulsivity in the classroom where
she was not performing well. The same problems were evident in the home as well. A visual T.O.V.A. and
an Auditory T.O.V.A. were administered to determine her strengths and challenges with visual and auditory
processing.

Visual T.O.V.A. for Case #4

T.O.V.A. Interpretation: The results of this T.O.V.A. are not within normal limits and the overall pattern of
performance suggests an attention problem, including ADHD.

Session and Response Validity: acceptable

Treatment: none recorded.

Comparison to the Normative Sample: The overall performance was not within normal limits. Response
Time Variability (RTV) was borderline in quarters 1 and 2 and not within normal limits in quarter 3. Response
Time (RT) was borderline slow in quarter 1 and gradually increased in quarters 2, 3, and 4. Commissions (a
measure of impulsivity) were within normal limits in all four quarters but were significantly higher in quarter
3. Omissions (a measure of inattention) were within normal limits in Half 1 but were significantly deviant
(high) in Half 2. There is one set of three omissions in a row in quarter 4. As noted elsewhere in the
Manual, this could be indicative of an underlying neurological problem, such as narcolepsy or seizures, and
is reason for a referral to a neurologist. Overall, she had difficulty with consistency and speed in half 1 (low
arousal), had difficulty with impulsivity in the change to half 2(high arousal) and had difficulty with attention
throughout half 2 (high arousal).

Attention Performance Index: -2.59. Her performance was similar to that of someone with ADHD.

Note: Subject was retested one week later at a similar time of day on the Auditory T.O.V.A. to compare her
performance to her Visual T.O.V.A.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
98 90 90 118 85 83 101 110 102 100 80 88 109 84 97 72
T.O.V.A. Clinical Manual 9 T.O.V.A. ® PROTOCOLS

Auditory T.O.V.A. for Case #4

T.O.V.A. Interpretation: The results of this T.O.V.A. are not within normal limits and the overall pattern of
performance suggests an attention problem, including ADHD.

Session and Response Validity: acceptable

Treatment: none recorded.

Comparison to the Normative Sample: The overall performance was not within normal limits. Her per-
formance on the Auditory T.O.V.A. was significantly worse than on the Visual T.O.V.A. for all four variables.
Interestingly, her Response Time was fastest in quarter 3 when she made the most Commission errors.
When she slowed in quarter 4, her Commissions improved. Omissions, which were worse in Half 1, oc-
curred in bunches (3-7 in a row) twice in quarter 3 and six times in quarter 4, rather than the usual scattered
pattern in an attention disorder. These are shown in the Raw Data Tables in the report. As noted else-
where in the Manual, this could be indicative of an underlying neurological problem, such as narcolepsy or
seizures, and is reason for a referral to a neurologist.

Notes: The Attention Performance Index research for the Auditory T.O.V.A. is pending.

Up to 10-12% of people process visual differently than auditory information; hence, as in this case, the
recommendation to do both Visual and Auditory Screening T.O.V.A.

The subject’s performance is not within normal limits on both the Auditory T.O.V.A. and the Visual T.O.V.A.
As the Auditory T.O.V.A. is worse, some clinicians use it as a baseline while others use the Visual T.O.V.A.
or both. Treatment, including school and home strategies (see Individualized Success Strategies-Home
and School), should take into account the need to address both sensory domains.

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 RT Variability Response Time Commission Errors Omission Errors
120 120 120 120
110 110 110 110
Standard Score

100 100 100 100

90 90 90 90
80 80 80 80
70 70 70 70
60 60 60 60
50 50 50 50
40 40 40 40
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
85 85 58 90 84 88 89 101 110 109 92 102 95 92 <40 46
T.O.V.A. Clinical Manual 10 T.O.V.A. OBSERVER RATING FORM

Part III

Appendices

10 T.O.V.A. Observer Rating Form

For a copy of the T.O.V.A. observer Rating Form, please contact The TOVA Company.

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T.O.V.A. Clinical Manual 11 DSM IV SYMPTOM CHECKLIST

11 DSM IV Symptom Checklist

Please check all that apply.

2 Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other
activities.

2 Often has difficulty sustaining attention in tasks or play activities.

2 Often does not seem to listen when spoken to directly.
2 Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the
workplace (not due to oppositional behavior or failure to understand instructions).

2 Often has difficulty organizing tasks and activities.

2 Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as
schoolwork or homework).

2 Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or
tools).

2 Is often easily distracted by extraneous stimuli.

2 Is often forgetful in daily activities.
2 Often fidgets with hands or feet or squirms in seat.
2 Often leaves seat in classroom or in other situations in which remaining seated is expected.
2 Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults,
may be limited to subjective feelings of restlessness).

2 Often has difficulty playing or engaging in leisure activities quietly.

2 Is often “on the go” or often acts as if “driven by a motor”.
2 Often talks excessively.
2 Often blurts out answers before questions have been completed.
2 Often has difficulty awaiting turn.
2 Often interrupts or intrudes on others (e.g. butts into conversations or games).

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T.O.V.A. Clinical Manual 11 DSM IV SYMPTOM CHECKLIST

Have these behaviors persisted for more than 6 months? YES NO Don’t know
Have these behaviors been maladaptive and inconsistent with development level? YES NO Don’t know
Were these behaviors present before age 7? YES NO Don’t know
Do these behaviors occur in more than one setting
(e.g. at home and at school or at home and at work)? YES NO Don’t know
Have these behaviors impaired social relationships? YES NO Don’t know
Have these behaviors impaired academic or work performance? YES NO Don’t know
Has there ever been any other psychiatric or psychological diagnosis before? YES NO Don’t know
If so, what and when?

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