Michael Boivin and the T.O.V.A.

This month's featured article and images are by longtime T.O.V.A. user Michael Boivin. Dr. Boivin's work in Uganda is a wonderful example of the many projects in the world using the T.O.V.A. for the benefit of others. If you are considering research or would like to send us an article about your work with the T.O.V.A., we would like to hear from you. Whether you are in a clinical, educational, research or industry setting, we value your stories and your experience.

Michael Boivin and the T.O.V.A.

In 1993 I spent six weeks in Laos, training pediatricians in developmental assessment methods and validating the adaptation of such tests as the T.O.V.A. with school-age children in this cross-cultural setting (Boivin et al., 1996). Then, in 1997 I traveled to Senegal, West Africa to evaluate the neurocognitive effects of cerebral malaria in surviving children. Cerebral malaria (CM) is a complication of P. falciparum type of malaria, defined by coma and malaria-specific retinopathies and often accompanied by seizure. More than a million children become ill each year with this life-threatening form of malaria, and over 95% of these cases occur in sub-Saharan Africa (Snow et al., 2005). I used the T.O.V.A. visual test that year to evaluate attention and impulsivity in CM survivors, both at Albert Royer Pediatric Hospital in Dakar and at a weekly outpatient health clinic near Bandia, situated in a rural district outside of Dakar. Because the clinic itself in Bandia was small and overcrowded, we administered our neuropsychological tests, including the T.O.V.A., on a reed mat on the ground outside the clinic in a tree-shaded area. None of these children had ever touched a computer before, and ours was powered by a car battery as the dry Sahel wind occasionally blew dust and sand over our keyboard and screen.

Despite the challenges of using the T.O.V.A. in this setting, we found that the children adapted quickly to the test and that it proved sensitive to the neurocognitive sequelae that were significantly elevated in our CM sample (Boivin, 2002). When compared to similar children without a history of CM or other brain injury, CM survivors had significantly poorer attention measures (% error omissions, correct response time variability, ADHD score). These measures were predictive of significantly poorer performance on the Kaufman Assessment Battery for Children (K-ABC) Sequential and Simultaneous Processing domains.

In 2003, I received an Africa Regional Research Fulbright award to continue my study of the neurocognitive effects of cerebral malaria. With the support of a Fogarty NIH R21 research grant, our study team that year was able to administer the T.O.V.A. and K-ABC to children admitted to Mulago Hospital (Kampala, Uganda) for cerebral malaria, comparing them to malaria outpatients and to siblings from those households without a history of CM or other brain injury. We documented neurocognitive deficits among our CM survivors at 6 months and at 2 years post illness, observing that the T.O.V.A. D-Prime measure of signal detection performance was a very sensitive measure to the effects of CM (Boivin et al., 2007, John et al., 2008a). Certain immunological measures of severity of acute illness at hospitalization for these children were also predictive of T.O.V.A. and K-ABC deficits at follow-up (John et al., 2008b).

We are presently using the T.O.V.A. to gauge the neurocognitive benefits of a computerized cognitive rehabilitation intervention for Ugandan survivors of severe malaria (Bangirana et al., 2009, Bangirana et al., 2006). This coming year we hope to publish a replication of these findings using the T.O.V.A. in a follow-up study of Malawian CM survivors (Birbeck et al., 2010, Boivin et al., 2010b). We also have an NIH grant pending that will allow us to expand this intervention research using the T.O.V.A. to help document training benefits with Ugandan CM survivors, and we are submitting a proposal to use the T.O.V.A. to document the treatment benefits of Ritalin with Malawian CM survivors with ADHD acquired from their illness.

Michael Boivin, PhD MPH, Associate Professor in the International Neurologic and Psychiatric Epidemiology Program at Michigan State University and an adjunct research investigator with the Neuropsychology Section at the University of Michigan. He has a PhD degree in experimental analysis of behavior from Western Michigan University and an MPH degree from the University of Michigan. A former Fulbright research scholar to the DR Congo (1990-91) and Uganda (2003-04), he presently helps lead NIH-sponsored studies in Uganda pertaining to the neurocognitive effects of HIV subtype in children, the neurodevelopmental benefits of caregiver training to enrich the home environment of very young children with HIV, and factors affecting neurocognitive disability in rural Ugandan children affected by HIV.


BANGIRANA, P., GIORDANI, B., JOHN, C. C., PAGE, C., OPOKA, R. O. & BOIVIN, M. J. (2009) Immediate neuropsychological and behavioral benefits of computerized cognitive rehabilitation in Ugandan pediatric cerebral malaria survivors. J Dev Behav Pediatr, 30, 310-8.

BANGIRANA, P., IDRO, R., JOHN, C. C. & BOIVIN, M. J. (2006) Rehabilitation for cognitive impairments after cerebral malaria in African children: strategies and limitations. Trop Med Int Health, 11, 1341-9.

BIRBECK, G. L., MOLYNEUX, M. E., KAPLAN, P. W., SEYDEL, K. B., CHIMALIZENI, Y. F., KAWAZA, K. & TAYLOR, T. E. (2010) The Blantyre malaria project epilepsy study (BMPES): neurologic outcomes in a prospective exposure-control study of retinopathy-positive pediatric cerebral malaria survivors. Lancet Neurology, in press.

BOIVIN, M. J. (2002) Effects of early cerebral malaria on cognitive ability in Senegalese children. J Dev Behav Pediatr, 23, 353-64.

BOIVIN, M. J., BANGIRANA, P., BYARUGABA, J., OPOKA, R. O., IDRO, R., JUREK, A. M. & JOHN, C. C. (2007) Cognitive impairment after cerebral malaria in children: a prospective study. Pediatrics, 119, e360-366.

BOIVIN, M. J., BUSMAN, R. A., PARIKH, S. M., BANGIRANA, P., PAGE, C. F., OPOKA, R. O. & GIORDANI, B. (2010a) A pilot study of the neuropsychological benefits of computerized cognitive rehabilitation in Ugandan children with HIV. Neuropsychology, 24, 667-73.

BOIVIN, M. J., CHOUNRAMANY, C., GIORDANI, B., XAISIDA, S. & CHOULAMOUNTRY, L. (1996) Validating a cognitive ability testing protocol with Lao children for community development applications. Neuropsychology, 10, 588-599.

BOIVIN, M. J. & GIORDANI, B. (2009) Neuropsychological assessment of African children: Evidence for a universal basis to cognitive ability. IN CHIAO, J. Y. (Ed.) Cultural Neuroscience: Cultural Influences on Brain Function. New York, NY, Elsevier Publications.

BOIVIN, M. J., GLADSTONE, M. J., VOKHIWA, M., BIRBECK, G. L., MAGEN, J. G., PAGE, C., SEMRUD-CLIKEMAN, M., KAUYE, F. & TAYLOR, T. E. (2010b) Developmental outcomes in Malawian children with retinopathy-confirmed cerebral malaria. Pediatrics, submitted for publication.

BOIVIN, M. J., RUEL, T. D., BOAL, H. E., BANGIRANA, P., CAO, H., ELLER, L.-A., CHARLEBOIS, E., HAVLIR, D. V., KAMYA, M. R., ACHAN, J., AKELLO, C. & WONG, J. K. (2010c) HIV Subtype A is associated with poorer neuropsychological performance compared to subtype D in ART-naïve Ugandan children. AIDS, in press.

JOHN, C. C., BANGIRANA, P., BYARUGABA, J., OPOKA, R. O., IDRO, R., JUREK, A. M., WU, B. & BOIVIN, M. J. (2008a) Cerebral malaria in children is associated with long-term cognitive impairment. Pediatrics, 122, e92-9.

JOHN, C. C., PANOSKALTSIS-MORTARI, A., OPOKA, R. O., PARK, G. S., ORCHARD, P. J., JUREK, A. M., IDRO, R., BYARUGABA, J. & BOIVIN, M. J. (2008b) Cerebrospinal fluid cytokine levels and cognitive impairment in cerebral malaria. Am J Trop Med Hyg, 78, 198-205.

SNOW, R. W., GUERRA, C. A., NOOR, A. M., MYINT, H. Y. & HAY, S. I. (2005) The global distribution of clinical episodes of Plasmodium falciparum malaria. Nature, 434, 214-7.