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Test of Variables of Attention (TOVA)
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Supplemental-Highly Recommended: Mitochondrial Disease (Mito):
Recommendations for use: Indicated for studies that measure cognitive attention span.
Supplemental: Cerebral Palsy (CP), Epilepsy, and Myalgic Encephalomyelitis/Chronic fatigue syndrome (ME/CFS)
Short Description of Instrument
The Test of Variables of Attention (TOVA) assesses sustained visual attention and inhibition of impulsivity over time.
The TOVA is a computerized measure of attention and impulsivity commonly used in the assessment of attention-deficit hyperactivity disorder (ADHD). The test has visual and auditory versions. In each, two simple stimuli are presented (either squares or tones), one designated as a target, one a nontarget. Participants are asked to respond to targets as quickly and accurately as they can by pressing a small, handheld microswitch. There are multiple inter-stimulus intervals. Thus, this test reflects, in part, inhibitory control. For a test that uses a more traditional continuous performance paradigm to assess primarily vigilance (as opposed to inhibitory control), the TOVA may also be considered (Test of Variables of Attention; Greenberg, 2000). The stimuli used were selected to be simple and culture free, and as it does not require familiarity with letters, it may be more suitable for those not familiar with the English language and alphabet, pre-literate children and individuals with greater cognitive impairment.
Age range: TOVA visual, ages 4-80+; TOVA auditory, ages 6-29
Administration: Computerized testing with micro-switch response
Administration Time: 21.6 minutes
Scoring Estimate: Automatic computer scored
Primary Dependent Measures: It was the consensus that there is presently insufficient empirical support to recommend one dependent measure as primary.
Vendor: Multi-Health Systems, Inc. (MHS), PO. Box 950, North Towanda, NY, 14120-0950
Comments/Special Instructions
Responses are compared to a normative distribution, and also to a study of individuals diagnosed with ADHD.
Scoring and Psychometric Properties
Scoring: TOVA is computer administered and computer scored. The scoring program provides a report including variability of response time (consistency), response time, commission (impulsivity), errors of omission (inattention), post-commission response times, multiple and anticipatory responses, and an ADHD score, which is a comparison to an age/gender specific ADHD group.
The TOVA immediately analyzes the results quarter by quarter and provides written interpretation and graphics.
Psychometric Properties: TOVA correctly identified 87% of non-ADHD and 90% of ADHD subjects (discriminant analysis). The test can assist in identifying attention deficits from other causes such as traumatic brain injury, sleep disorders, trauma and other sources.
Strengths: The TOVA uses geometric or auditory stimuli to minimize the impact of learning disabilities, cultural differences (Boivin 2002) and visual impairment, and is designed to minimize practice effects so it can be used for serial assessments. A microswitch response button is used to increase accuracy in response time measurement and to minimize motor fatigue. A brief version is available for children as young as 4. Can be easily administered by an assistant with simple training.
The TOVA has been used to evaluate change over very brief treatment intervals (Goez et al., 2012), as well as across a variety of disease populations that may mimic symptoms of mitochondrial disorders including depression (Canpolat et al., 2014) and HIV (Ruel et al., 2012).
Weaknesses: Requires specific configuration of computer and specialized microswitch response button. Lengthy to administer, and typically examinees do not enjoy this test. Repetitive flashing associated with the visual version of the task may pose a risk of seizures to those with photosensitive epilepsy.
Cerebral Palsy-specific: There is very limited use of the TOVA in research on CP, including initial evidence to suggest that biofeedback has positive effects on aspects of attention.
Key References:
Greenberg, L.M. (1991). T.O.V.A.™ interpretation manual. Minneapolis, MN: Author.
Greenberg LM, Waldman ID. Developmental normative data on the test of variables of attention (T.O.V.A.). J Child Psychol Psychiatry. 1993 Sep;34(6):1019-30.
Additional References:
Boivin MJ. Effects of early cerebral malaria on cognitive ability in Senegalese children. J Dev Behav Ped. 2002Oct;23(5):353-64.
Canpolat S, Kirpinar I, Deveci E, Aksoy H, Bayraktutan Z, Eren I, Demir R, Selek S, Aydin N. Relationship of asymmetrical dimethylarginine, nitric oxide, and sustained attention during attack in patients with major depressive disorder. ScientificWorldJournal. 2014 Jan 16;2014:624395.
Fernandez-Marcos T, de la Fuente C, Santacreu J. Test-retest reliability and convergent validity of attention measures. Applied Neuropsychology Adult. 2018 Sep-Oct;25(5):464-72.
Goez HR, Scott O, Nevo N, Bennett-Back O, Zelnik N. Using the test of variables of attention to determine the effectiveness of modafinil in children with attention-deficit hyperactivity disorder (ADHD): a prospective methylphenidate-controlled trial. J Child Neurol. 2012 Dec;27(12):1547-52.
Manor I, Meidad S, Zalsman G, Zemishlany Z, Tyano S, Weizman A. Objective versus subjective assessment of methylphenidate response. Child Psychiatry Hum Dev. 2008 Sep;39(3):273-82.
Ruel TD, Boivin MJ, Boal HE, Bangirana P, Charlebois E, Havlir DV, Rosenthal PJ, Dorsey G, Achan J, Akello C, Kamya MR, Wong JK. Neurocognitive and motor deficits in HIV-infected Ugandan children with high CD4 cell counts. Clin Infect Dis. 2012 Apr;54(7):1001-9.
Document last updated March 2024
Recommended Instrument for
CP, Epilepsy, Mito and ME/CFS