The T.O.V.A.Times In This Issue

MAY 2008
The T.O.V.A.Times
In This Issue
New Workshop
Case of the Month
Medical Billing Codes
Frequently Asked
• Meet the T.O.V.A. Team!
New Workshop Format Starting This Fall
We have been conducting numerous T.O.V.A. workshops across the country over the past couple of years. It gives us a
chance to get out and meet you - the T.O.V.A. users. It also gives us feedback about what you are looking for from the
T.O.V.A. and what you need for training.
Starting this fall we will begin offering a 1 1/2 day workshop format that covers more of the things you are looking for whether you are a new user or a long-time T.O.V.A. customer.
The first half day will cover the basics and is optional. We will cover in-depth how to load and configure the T.O.V.A. We
will talk about how to administer a T.O.V.A. that stays true to the standardization process. We will also cover how to read
and interpret the T.O.V.A. report. This part of the workshop is appropriate for anyone who is new to the T.O.V.A. or anyone
who needs a refresher on how to get up and running. There is a separate registration fee for this class so that you can send
more individuals from your office who may be administering the T.O.V.A. At the end of the session each person will
receive a Certificate of Completion representing that they have been properly trained on administering the T.O.V.A.
The second part of the workshop is broken in to two distinct parts. The first half of the full day workshop is an in-depth
overview of the T.O.V.A. and the new T.O.V.A. Process Interpretation. In the second half of the day, discussion is around
how to use the T.O.V.A. in your practice as an integrated part of diagnosis and case management. We will also be talking
about the upcoming release of the T.O.V.A. 8.0 later this year.
For more information on this new workshop please visit our workshop information page at
MAY 2008
T.O.V.A.™ Case of the Month
Is this T.O.V.A. for Real?
What if there was a way to both document the presence of attention impairment and confirm that the symptoms being
reported are genuine?
Health care professionals are often reluctant to diagnose and treat ADHD when the possibility of medication misuse, abuse,
or redistribution is a concern. The need for caution results in many people from high-risk groups (such as college students)
going untreated.
Recent research with the T.O.V.A. has revealed important clues about detecting “fake bad” responding in subjects who may
(for their own reasons) be exaggerating impairment. This means that you can feel confident about treating cases from highrisk groups where you–and the T.O.V.A.–judge attention complaints to be genuine.
Below, we show T.O.V.A. results from a 19-year-old college student who presented to his college’s student health center
with complaints of poor ability to sustain attention, difficulty focusing, and problems meeting the demands of his
coursework. He asked about receiving treatment for ADHD. This is a common situation in which the health care provider
may have concerns regarding the possible motivation for diagnosis. Can the T.O.V.A. help?
Let’s look at how he did:
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Response Time Variability
Response Time
Commission Errors
Omission Errors
ADHD Score: -10.80
* significantly deviant
This performance is terrible–strikingly so. Across the board we see severe problems with slow and variable response time,
and numerous omission errors. Does this young man have a significant attention problem, some other medical or
neurological problem, or could he possibly be exaggerating his impairment? In other words, is this T.O.V.A. for real?
Research by Leark, Dixon, Hoffman & Huynh (2002) investigated patterns of performance on the T.O.V.A. in persons
instructed to perform their best one time, and to “fake bad” another time. In a different study, Henry (2005) compared
T.O.V.A. performance in groups judged to be “probably malingering” and “probably not malingering” based upon their
responding on other measures specifically designed to detect deliberately poor performance.
Some of the data from these studies was available for recent further analysis designed to identify a general set of rules for
detection of “fake bad” performance on the T.O.V.A. This work yielded a number of criteria that now make up a
preliminary algorithm for detection of deliberately poor performance on the T.O.V.A., and which will be included in the
T.O.V.A. 8.0 report (Hughes, Leark, Henry, Johnson & Greenberg, 2008).
This model utilizes both overt (large numbers of errors) and subtle (analysis of reaction time data) criteria, and represents a
robust method for establishing the validity of reported symptoms. Three of the criteria are:
1) Extremely low scores for Omissions and/or Commissions
2) Extremely low score for Variability
3) Failure to show evidence of post-error slowing (post-commission error reaction time ≤ average correct reaction time).
Are you wondering about “post-error slowing?” Most of the time, when a person taking the T.O.V.A. makes a commission
error, they slow down their response time on the next correct response. It is as if they unconsciously “flinch” at having
made the error, and somehow resolve to “be more careful.” Post-error slowing is a common phenomenon on the T.O.V.A.
and similar tasks.
MAY 2008
You can look for evidence of post-error slowing in the reaction time data shown in the Tabulated Raw Data table on Form 5
of the T.O.V.A. protocol. A portion of that table is shown below. With the information in this table, we can compare
average correct response times (the first row below) to average post-commission error response times (the third row).
Results Table
(Tabulated Raw Data)
Response Time (msec)
Commission Errors
Post-Comission Response Time (msec)
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Does our subject show evidence of post-error slowing?
He made no commission errors in Q2 (and there is some suggestion of a mild degree of post-error slowing in Q3); however,
the Total difference between correct response reaction time (the first row) and his post-commission error reaction time (the
third row) shows no evidence of post-error slowing. (In fact, his average response times following commission errors
tended to be slightly faster than average correct response times!).
When “post-error slowing” is not present, we can infer that the subject is not feeling that “flinch” when making errors.
Why aren’t they? One reason might be that those commission errors may have been made deliberately.
In our example case, the T.O.V.A. protocol meets all of three of our criteria for a “fake bad” T.O.V.A.: He produced an
extremely low score for omission errors (Rule 1), an extremely low variability score (Rule 2), and failed to demonstrate
“post-error slowing” (Rule 3). Based on this model, our 19-year-old college student may have an agenda, and the treating
professional should approach diagnosis and treatment with some degree of caution (and maybe refer for a more in-depth
evaluation that includes additional symptom validity tests).
You should note that these T.O.V.A. symptom validity rules are not reliable with children and adolescents, and should not be
used to determine symptom validity in these groups. In addition, these guidelines only help us determine the validity of the
T.O.V.A. which may or may not reflect a general pattern of symptom exaggeration. Also note that other portions of an
assessment may be valid.
Finally, you should also remember that patients may exaggerate their degree of impairment for a number of reasons. When
exaggeration is suspected, it is up to the clinician to try to determine why symptom exaggeration may have occurred.
Sometimes it IS frank malingering for secondary gain, but sometimes symptom exaggeration is a patient’s way of
communicating that they feel they have a serious problem and really do want to receive our help.
You can learn more about T.O.V.A. protocol analysis in the Guide to Clinical Interpretation of the T.O.V.A., available free
of charge on The TOVA Company website at You can also learn more about
interpreting the T.O.V.A. by attending one of our inexpensive workshops.
Our goal is to continue to lead the field in objective measures of attention. T.O.V.A. 8.0 will include these and other
symptom validity rules, and a number of other significant enhancements. Keep reading the T.O.V.A. Times newsletter, and
watch The TOVA Company web site ( for more information!
Leark, R. A., Dixon, D., Hoffman, T., &Huynh, D. (2002). Fake bad test response bias effects on the Test of Variables of
Attention. Archives of Clinical Neuropsychology, 17, 335–342.
Henry, G (2005). Probable malingering and performance on the Test of Variables of Attention. The Clinical
Neuropsychologist, 19:1, 121-129.
Hughes, S., Leark, R., Henry, G., Johnson.., E. & Greenberg., L, (2008, June). Using the Test of Variables of Attention
(T.O.V.A.) to Detect Deliberate Poor Performance During Assessment of Attention. Poster session presented at the annual
meeting of the American Academy of Clinical Neuropsychology, June, 2008, Boston, MA.
MAY 2008
Medical Billing Codes and the T.O.V.A.
Medical billing has not gotten easier in recent years, and some T.O.V.A. users have questions about how they can ensure
third-party reimbursement for using the T.O.V.A. Billing practices vary widely from region to region in the US, and even
across third-party payers. While there is no substitute for a consultation with a competent coding expert, here are some
guidelines that you might find useful.
Billing Time: When calculating how much time is spent using the T.O.V.A., we recommend that you report time as
accurately as possible by tracking the amount of time spent for each component of a visit. This includes patient and/or
caregiver interview, test administration, test interpretation, and report writing. Psychological testing codes normally require
rounding up or down at the 30-minute mark. That is, testing of less than 30 minutes duration may not be separately
reimbursable, but may be “bundled” into other services provided during a visit. Testing that requires greater than 30
minutes should be rounded to the next full unit (hour).
The T.O.V.A. typically requires about 40-50 minutes for administration, interpretation to patients and/or caregivers, and
documentation, and most T.O.V.A. users bill one unit of time (one hour) for these services.
Billing Codes: For psychological and neuropsychological testing, medical providers utilize the same billing codes that are
used by psychologists. In addition, physicians are able to utilize E/M codes. If you cannot work out reimbursement for the
T.O.V.A. from a specific third-party payer, you should be able to subsume T.O.V.A. administration and interpretation in an
E/M code for an office visit. However, in general, you should be able to utilize any one of several common CPT codes.
What to know more? Visit our website at for additional information.
Frequently Asked Questions
When should I use the auditory T.O.V.A.-A.?
An estimated 12% of people with an attention disorder process visual information significantly differently than auditory
information. Clinically, you can sometimes identify these individuals by history- some people have most difficulty
processing auditory information, especially in situations with extraneous noises like some classrooms and work settings that
distract them although they can function pretty well with written information. Others have most difficulty processing written
information, like reading and homework assignments.
This explains why the visual T.O.V.A performance of some individuals with ADHD may be within normal limits while the
auditory T.O.V.A.-A. performance may be significantly deviant from the norm. And vise-versa.
In addition, data from our extensive norming studies indicate that auditory processing difficulties are more common and
more severe than visual processing problems, especially in persons with ADHD.
Thus, we now recommend that both the T.O.V.A. and T.O.V.A.-A. be used in the diagnostic work-up of attention disorders,
and that one or the other would subsequently be used in monitoring the treatment and course of the disorder.
Okay, so why are there two different tests? Why not combine them? There are three reasons:
1. Both T.O.V.A.s are deliberately long (21.6 minutes or 10.8 minutes for 4-6 years old children) to “catch” persons with
attention disorders who can compensate for 10 or even 15 minutes.
2. Using both visual and auditory modalities together introduces novelty that can be over-stimulating to some and alerting
to others.
3. It’s important to accurately determine which modalities are compromised so that treatment can be specifically targeted.
MAY 2008
Meet the T.O.V.A. Team!
Our first profile is of Larry Greenberg, the author of the T.O.V.A. He is
the President of the Board of The TOVA Company and Professor
Emeritus of Psychiatry, University of Minnesota. He lives predominantly
in Mexico with his wife, Carol Kindschi.
Shaped by my training in Pediatrics, General Psychiatry, and Child and
Adolescent Psychiatry with an emphasis on Attachment Theory and
SandPlay Therapy, a developmental orientation permeates my personal
life and my career as an educator, therapist, and researcher. Helping
children and adults live life more fully and working alongside Carol and
our son, Andrew, who is our Director of Product Development, are both
personally and professionally very rewarding.
Carol and I live part-time in Ajijic (a town near Guadalajara, Mexico)
where we can direct The TOVA Company while enjoying the temperate
climate and are helping to develop a small sustainable community in
which we hope to provide a life-enriching, “recharging” experience for
therapists. We are also able to visit our three grandchildren (and their
parents) frequently in Portland, OR.
My professional career has been closely linked to the development of the
T.O.V.A. and what we now call evidence-based research. My first
psychiatric research project, begun in 1966, included the predecessor of
the T.O.V.A., a large electronic rack, affectionately known as “Herman.”
We were studying several medications, including a tranquilizer and an amphetamine, that were then being used to treat
children with the Hyperkinetic Reaction of Childhood. We were confounded by the results of the behavior ratings- the
teachers clearly preferred the amphetamine and rated the tranquilizer as less effective than placebo. The parents rated the
two medications exactly the opposite. Herman’s data explained the discrepancy- the teachers recognized that the
amphetamine-treated children were much more attentive and productive while the parents focused on the decreased
disruptive, destructive behavior with the tranquilizer (because of excessive sedation). Thus, I learned early to value objective
measures of behavior and not rely solely on subjective behavior measures and reports.
With subsequent versions of the T.O.V.A., we learned that many children being treated didn’t actually have ADHD, that
excessive amounts of medication were being prescribed, and that many children who did have an attention disorder weren’t
being referred because they weren’t bothering anyone, or because the underlying attention disorder was “masked” by comorbid conditions, especially conduct disorder, depression, and anxiety.
I’m pleased to see the T.O.V.A. contributing to the quality of life and look forward to what’s next.
800.PAY.ATTN [email protected]
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