NIH Ds Test

NIH Toolbox® for Assessment of
Neurological and Behavioral Function
Administrator’s Manual
iPad App Version 1.17 and up
© 2006-2018 National Institutes of Health and Northwestern University

Table of Contents
Introduction to the NIH Toolbox App ........................................................................................... 4
A.1 What is the NIH Toolbox App? ...................................................................................................................... 4
A.2 Development of the NIH Toolbox .................................................................................................................. 4
A.3 Characteristics of the NIH Toolbox App ........................................................................................................ 5
Learning about the NIH Toolbox App............................................................................................ 6
B.1 NIH Toolbox App Structure............................................................................................................................ 6
B.2 Getting the NIH Toolbox App ........................................................................................................................ 8
B.2.1 Hardware and Software Needed to Use the NIH Toolbox App .............................................................. 8
B.2.2 Downloading and Opening the NIH Toolbox App ....................................................................................... 10
B.3 NIH Toolbox Support ................................................................................................................................... 10
B.4 Using the NIH Toolbox App ......................................................................................................................... 11
B.4.1 NIH Toolbox App at a Glance...................................................................................................................... 11
B.4.2 Participants................................................................................................................................................. 12
B.4.3 Batteries ..................................................................................................................................................... 28
B.4.4 Export Data................................................................................................................................................. 32
B.4.5 NIH Toolbox App Settings ........................................................................................................................... 39
B.4.6 Audit Logs ................................................................................................................................................... 41
Administering NIH Toolbox ........................................................................................................ 42
C.1 NIH Toolbox Touch Screen Tutorial ............................................................................................................. 43
C.2 Cognition Domain ........................................................................................................................................ 44
C.2.1 NIH Toolbox Picture Vocabulary Test .................................................................................................. 46
C.2.2 NIH Toolbox Flanker Inhibitory Control and Attention Test ................................................................ 49
C.2.3 NIH Toolbox List Sorting Working Memory Test.................................................................................. 61
C.2.4 NIH Toolbox Dimensional Change Card Sort Test (DCCS) .................................................................... 82
C.2.5 NIH Toolbox Pattern Comparison Processing Speed Test .................................................................. 109
C.2.6 NIH Toolbox Picture Sequence Memory Test ..................................................................................... 118
C.2.7 NIH Toolbox Oral Reading Recognition Test ...................................................................................... 137
C.2.8 Oral Symbol Digit Test ....................................................................................................................... 140
C.2.9 Auditory Verbal Learning Test (Rey) .................................................................................................. 142
C.3 Emotion Domain ........................................................................................................................................ 143
C.3.1 Emotion Constructs............................................................................................................................ 145
C.3.2 General Instructions .......................................................................................................................... 147
C.3.3 NIH Toolbox Emotion Age-Specific Instructions and Instruments ..................................................... 147
C.3.4 Emotion measures available in the NIH Toolbox App........................................................................ 153
C.4 Motor Domain ........................................................................................................................................... 156
C.4.1 NIH Toolbox 9-Hole Pegboard Dexterity Test .................................................................................... 156
C.4.2 NIH Toolbox Grip Strength Test ......................................................................................................... 161
C.4.3 NIH Toolbox Standing Balance Test ................................................................................................... 164
C.4.4 NIH Toolbox 4-Meter Walk Gait Speed Test ...................................................................................... 180
C.4.5 NIH Toolbox 2-Minute Walk Endurance Test..................................................................................... 183
C.5 Sensation Domain...................................................................................................................................... 187
C.5.1 NIH Toolbox Pain Interference Survey (18+) & NIH Toolbox Pain Intensity Survey (18+) .................. 189
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C.5.2 NIH Toolbox Odor Identification Test ................................................................................................ 190
C.5.3 NIH Toolbox Visual Acuity Test .......................................................................................................... 196
C.5.4 NIH Toolbox Words-in-Noise Test ...................................................................................................... 202
C.5.5 NIH Toolbox Regional Taste Intensity Test ........................................................................................ 204
Administering PROMIS ............................................................................................................. 210
D.1 PROMIS Instruments List ........................................................................................................................... 211
Neuro-QoL ................................................................................................................................... 3
E.1 Neuro-QoL Instrument List ............................................................................................................................ 5
TBI-QOL ........................................................................................................................................ 6
F.1 TBI-QOL Instrument List ................................................................................................................................ 7
SCI-QOL ........................................................................................................................................ 9
G.1 SCI-QOL Instrument List .............................................................................................................................. 10
SCI-FI .......................................................................................................................................... 11
Appendix 1 – NIH Toolbox App Terms and Conditions ....................................................................... 13
Appendix 2 – Determining Handedness ............................................................................................. 22
Appendix 3 – Pausing, Stopping, Resuming Rules .............................................................................. 23
Cognition ............................................................................................................................................................. 23
Emotion ............................................................................................................................................................... 27
Motor ................................................................................................................................................................... 28
Sensation ............................................................................................................................................................. 30
Appendix 4 – NIH Toolbox Equipment and Materials ........................................................................ 35
Appendix 5 – Key to Instrument Name Abbreviations ....................................................................... 39
Appendix 6 – NIH Toolbox 4-Meter Walk Gait Speed Test and 2-Minute Walk Endurance Test
Walking Course ................................................................................................................................. 43
Appendix 7 – NIH Toolbox Regional Taste Test Materials and Taste Solutions Mixing Instructions ... 45
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Introduction to the NIH Toolbox App
A.1 What is the NIH Toolbox App?
The NIH Toolbox app provides access to the NIH Toolbox for Assessment of Neurological and
Behavioral Function, a standard set of valid, reliable and royalty-free tools for assessing cognitive,
emotional, motor and sensory function. Designed to benefit all scientists interested in investigating
behavioral and neurological function, the NIH Toolbox App is also relevant for students and clinicians
across a broad spectrum of health research. It is particularly well-suited for measuring outcomes in
longitudinal epidemiological studies along with prevention or intervention trials. NIH Toolbox measures
have been normed and validated across the lifespan in participants ages 3-85.
A.2 Development of the NIH Toolbox
In 2004, 15 Institutes, Centers and Offices at the National Institutes of Health (NIH) that support
neuroscience research formed a coalition called the Blueprint for Neuroscience Research. The NIH
Blueprint goal was to develop new instruments, resources and training opportunities to accelerate the
pace of discovery in neuroscience research. Because the research community had long sought the
development of standard instruments to measure cognitive and emotional health, in 2006 the NIH
Blueprint awarded a contract to develop an innovative approach to meet this need.
The NIH Toolbox was intended to include the following domains: Cognition, Emotion, Motor, and
Sensation. Initial literature and database reviews and a ‘Request for Information’ of NIH-funded
researchers identified the sub-domains for inclusion in the NIH Toolbox along with the criteria affecting
instrument selection, creation and norming.
NIH Toolbox validation studies were conducted across the entire age range, typically including 450-500
subjects, and statistically compared NIH Toolbox against existing “gold standard” measures, whenever
available. For tests using Item Response Theory (IRT) approaches to scoring, calibration samples
generally included several thousand participants, ensuring robust models. In total, data were collected
from more than 16,000 subjects as part of field-testing, calibration and validation activities.
The NIH Toolbox project conducted a large national norming study in both English and Spanish
languages. A sample of 4,859 participants, ages 3-85, representative of the U.S. population based on
gender, race/ethnicity, and socioeconomic status was administered all of the NIH Toolbox measures at
sites around the country. NIH Toolbox normative scores are now available for each year of age from 3
through 17, as well as for ages 18-29, 30-39, 40- 49, 50-59, 60-69, 70-79, and 80-85, allowing for
targeted, accurate comparisons for any research study participant groups against the U.S. population.
In 2012, the web-based version of NIH Toolbox was released to the general public and in 2015, the
iPad app version was released.
NIH Toolbox measures utilize several advanced approaches in item development, test construction,
and scoring. Two of these are Item Response Theory (IRT) and Computer Adaptive Testing (CAT),
which are used in a subset of instruments. IRT allows tests to be brief, yet precise and valid. Using IRT
methodology, sets of items are calibrated along a continuum that covers the full range of the construct
to be measured. This calibrated set of items enables the creation of CAT, a specialized type of
computer-based testing that enables administration of items based on individuals’ responses, with
minimal burden on participants and precise evaluation at the individual level.
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NIH Toolbox instrument development has focused on the continuity of assessments throughout the
lifespan. An expert team of early childhood and older adult assessment consultants was engaged to
provide guidelines for administration, to offer input on instrument development, and to review all NIH
Toolbox measures as they relate to the needs of young children and elderly participants.
A.3 Characteristics of the NIH Toolbox App
The use of the NIH Toolbox has grown significantly since public release of the web-based version in
2012. Beginning in 2015, the NIH Toolbox is available in the form of an iPad app that presents the
following user-friendly features and functions:
• Takes advantage of portable, easy-to-use technology

• Presents a complete stand-alone application – internet access is no longer required during test
administration
• Administering the tests can be easily mastered with practice
• Minimizes the use of custom hardware
• Features enhanced normative scores for individual tests and composites
• Allows results to be stored locally on the iPad or exported to the iCloud or a configurable web
address
• Provides basic reporting on an individual participant level
• Offers email support (help@nihtoolbox.org)
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Learning about the NIH Toolbox App
Users will find that the NIH Toolbox is a user-friendly and effective resource for assessing functioning
over time. This NIH Toolbox Administrator’s Manual and the NIH Toolbox eLearning Course are
designed to be used together when learning how to use the NIH Toolbox app. After reviewing sections
A and B of this Manual, an administrator should go through the eLearning course for the NIH Toolbox
app. Once an administrator has studied the eLearning course and completed practice sessions, each
instrument is easy to administer.
Once training is complete, this manual should be used for review as needed.
When used electronically, this manual includes hyperlinks that, when clicked on or touched, take the
user directly to the referenced section.
B.1 NIH Toolbox App Structure
Introduction – Domain, Battery, Instrument

To better understand the NIH Toolbox structure and to make informed choices as an administrator,
there are a number of terms that the user needs to understand.
Domain - The NIH Toolbox spans four domains or broad areas of health and function: Cognition,
Emotion, Motor and Sensation. Each domain includes multiple instruments that can be selected
individually or used as part of a preset battery.
Preset Battery – A pre-defined set of instruments intended to be administered together in a specific
order. The order of instruments within a preset battery cannot be changed. Individual instruments, or
additional batteries, can be added to an assessment, before or after the preset battery. Scores are
produced for each instrument in the battery as well as composites for the Cognition Battery and
summary scores for Emotion batteries.
Instrument - A set of items administered in a predetermined fashion that cannot be changed by the
administrator. Each instrument is an individual assessment resource that can be administered as a
stand-alone measure, as part of a preset battery, or as part of a custom battery. Instruments are also
referred to as “measures” and “tests” in this manual. All of these words are used interchangeably.
Item – A question or task within an instrument. The instrument is comprised of items.
Custom Battery – A user-created and named battery containing one or more instruments in any
desired order. A custom battery may be created by saving a custom list of instruments for use in future
assessments. Once a custom battery has been administered to a participant, it cannot be modified. If
a user wishes to edit the custom battery, it must be saved under a new, unique name.
Custom batteries are only available on the iPad on which it was created. Future releases may
enable a custom battery that can be shared across iPads with the same Apple ID. An administrator can
create a custom battery that contains instruments from more than one domain, and the battery can be
given in any order specified by that administrator.
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Assessment - A group of instruments given to a participant. These may or may not contain a custom
or preset battery.
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B.2 Getting the NIH Toolbox App
B.2.1 Hardware and Software Needed to Use the NIH Toolbox App
To get the NIH Toolbox App, you will need the following: an iPad and an Apple ID. These are
described in more detail below. The NIH Toolbox App is only available through the “App Store,” a digital
distribution platform for mobile apps on Apple devices. At this time, only an iPad version of the app has
been developed.
iPad
Please see the most updated hardware requirements at the NIHToolbox.desk.com site
To obtain the latest version of iOS, see Settings>General>Software Updates on your iPad.
Apple ID
You will need an Apple ID to use the App Store app, which comes pre-installed on your iPad.
An Apple ID is your all-in-one account used to log in to all Apple products. You may already have an
Apple ID. If this is the case, you may use this ID or you may want to consider setting up another Apple
ID for your NIH Toolbox activity. You can create an Apple ID as described below.
An Apple ID is associated with your billing information (i.e. credit card). While the NIH Toolbox
App is free to install, you must purchase a subscription to be able to score the instruments. More
information about pricing options can be found at nihtoolbox.org.
If you have an Apple ID that you can use for your NIH Toolbox activity, you may skip to Downloading
and Opening the NIH Toolbox App. Otherwise, the two ways to create an Apple ID are described
below.
How to Create an Apple ID on your iPad

1. From the Home Screen, tap Settings > iTunes & App Stores.
2. If an Apple ID is already signed in, tap the Apple ID name and then tap Sign Out.
3. Tap Create New Apple ID.
4. Choose the appropriate store by tapping Store, and select the country in which you are located.
5. Tap Done to confirm your selection, and then tap Next.
6. To proceed, agree to the Terms and Conditions and Apple Privacy Policy. You can opt to
have the Terms and Conditions and Privacy Policy emailed to you for easier reading by tapping
Send by Email. To do this, enter a valid email address, and then tap Send.
7. Tap the Agree button on the bottom-right of the page.
8. Tap Agree again when the confirmation appears.
9. After you've agreed to the terms and conditions, you'll need to enter an email address and
password, and choose three security questions, providing answers to each of them. The email
address you provide will be your new Apple ID. Enter your email address, and then tap Next.
You can also enter an optional rescue email address. We recommend that you provide this
rescue email address.
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10. If you're trying to create an account using an existing Apple ID, like your iCloud email address,
you'll receive a prompt telling you that your email address is already an Apple ID. Simply tap
Continue, and then tap Use Existing Account on the following screen.
11. Next, you'll be asked to enter your billing information. To choose a different Credit Card type,
tap one of the available options, and then tap Done. You will not be charged until/unless you
make a purchase.
12. After you've filled out all of the fields for your billing information, tap Next.
13. You will then see a screen that says “Verify Your Account.”
14. Tap Done and check your email for a verification email from Apple. If you need to set up email
on your iPhone, iPad, or iPod touch, learn how to add an email account to your iOS device (you
need to be connected to the Internet for this link to work)
15. Open the email, and tap the Verify Now link enclosed in the email to activate your account.
16. You will then be taken to a secure page to enter your new Apple ID and password.
17. After you've entered your email address and password, tap Verify Address.
18. To modify or change your account information; such as Apple ID, payment information, or billing
address, tap your account name located at the bottom of the page once you have signed in to
the iTunes Store. When prompted, tap View Account. You might be asked to enter your
account password again for verification.
19. To sign out of your iTunes Store account, simply tap your account name at the bottom of the
page in the App Store or iTunes Store.
How to create an Apple ID on your computer (Apple or Windows operating systems)
1. Open iTunes. If you don't have iTunes, you can download it here.
2. From the Store menu, choose Create Apple ID.
3. Click Continue.
4. To proceed, you'll need to agree to the Terms and Conditions and Apple Privacy
Policy. After you've read the terms, click the checkbox next to "I have read and agree
to these terms and conditions."
5. Click Agree.
6. Complete the form to create your free Apple ID. The form includes security questions
for your protection, and asks for an optional rescue email address (you need to be
connected to the Internet for this link to work). We recommend that you provide a
rescue email address.
7. After you've filled out the form, click Continue.
8. If you receive a warning that the email address you entered is already associated with
an Apple ID, follow these instructions about using an existing Apple ID (you need to be
connected to the Internet for this link to work) instead.
9. Provide a valid payment method and billing address. Your account will be charged only
when you make a purchase. No purchase is necessary, but Apple does require you to
enter a credit card number to set up an Apple ID.
10. Provide the required billing information and click Continue.
11. Next you will need to verify your email address. Check your email for a verification
email from Apple.
12. In the verification email you receive from Apple, click the Verify Now link.
13. You will be taken to the Apple ID page to verify your email address.
14. Enter your email address and the password you created when you established your
Apple ID.
15. Click Verify Address.
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B.2.2 Downloading and Opening the NIH Toolbox App
1. Tap on the App Store icon on your iPad.

2. Enter NIH Toolbox in the Search field in the upper right corner of the App Store and
tap Search.
3. Once the NIH Toolbox app is displayed, tap the Get button next to it. It will turn into an
INSTALL button.
4. Tap Install to confirm you wish to download and install the app. If you are already
signed in using your Apple ID, a pop up screen will ask you to provide your password.
If you are not signed in, you will be given the options of “Use Existing Apple ID,”
“Create New Apple ID” and “Cancel.”
5. Since you have already created your Apple ID, tap the Use Existing Apple ID button
and sign in using your Apple ID and password. At this point, the download will begin
and the NIH Toolbox app will become available on your iPad.
6. If you cannot see the app on your iPad after downloading, try swiping to the right or left
to see all of the apps installed on your iPad.
7. Open the NIH Toolbox App by tapping the NIH Toolbox icon.
8. Accept the NIH Toolbox app Terms and Conditions (see Appendix 1).
9. When opening the app for the first time, you will be asked to set up a passcode. You
will be asked to enter this passcode every time you open the app in the future. Keep
this passcode in a safe place.
The NIH Toolbox app is available through the app store and can be downloaded for free.
However, to use the app in its entirety, you will be asked to purchase a 12-month subscription for
$499.99. This subscription may be used on any iPad on which you install the NIH Toolbox app, as long
as you enter the same Apple ID used for purchase. The 12-month subscription will automatically renew
unless auto-renew is turned off at least 24 hours before the end of the current subscription period. No
cancellation of the current (paid) subscription is allowed during the subscription period. After expiration,
you will still have access to your data on the iPad, but you will no longer be able to create new
participants/patients or collect new data.
Prior to subscribing you may explore the app while in Trial Mode. Trial Mode allows access to the
instruments, batteries and running assessments. This will give you the opportunity to get comfortable
and delve into what the NIH Toolbox app has to offer and how it functions. However, while using the
app in the Trial Mode no data will be saved and you will not have access to the reports or data exports.
To begin collecting data you must subscribe to the app.
B.3 NIH Toolbox Support
To access a copy of this manual or view more resources about the NIH Toolbox, please visit
https://nihtoolbox.desk.com/
Contact help@nihtoolbox.org with questions, or to report technical problems.
The NIH Toolbox is more than a set of measures: we are a community of users, and NIH Toolbox
continues to evolve. Help us make this product the best it can be. If you have suggestions for changes
or corrections, please share them here: info@nihtoolbox.org.
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B.4 Using the NIH Toolbox App
B.4.1 NIH Toolbox App at a Glance
Once the app is launched, users will see 4 buttons on the home screen: Participants, Batteries and
Profiles, Export Data and Settings. This section of the manual is organized according to the functions
achieved by tapping one of those buttons. Data security is described at the end of the section.
Required setting: A passcode must be set on the iPad running the NIH Toolbox app, for security
purposes. The app will not launch if a passcode is not set.
Recommended setting: Disable all pop-up messages (i.e. calendar alerts) on the iPad running the
NIH Toolbox app. This will ensure smooth, uninterrupted data collection.
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B.4.2 Participants
Create a new participant
Step 1: Tap Add New Participant in the upper right corner of the Participant screen:
Step 2: Complete the new participant information:
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• Identifier – any alphanumeric combination or special symbols you wish to assign to this
participant. This is the only field that is ALWAYS required.
• Name – the participant’s name. This is the only field that is ALWAYS optional regardless of the
function you wish to use.
• Birthdate or Age – user to choose which of the two to enter for a participant
• Handedness (required); If unknown, please refer to Appendix 2 for a brief survey to determine
handedness
Please note that some of these fields may be required for some instruments. Examiners will be alerted
when launching an assessment if one or more required fields are missing based on the selection of
instruments. Error and Warning messages are described below in more detail.
If a participant is less than 18 years old and his/her Mother’s Education is unknown, examiners will be
asked to complete additional fields related to other family members’ education.
If the NIH Toolbox Picture Vocabulary Test or the NIH Toolbox Oral Reading Test is selected,
examiners will also see a Starting Education Level Override field. If an examiner feels that a participant
should begin the test at a level higher or lower than what would be appropriate for his/her
grade/education level, the examiner should use this feature. Using the override will affect the difficulty
of the initial items presented on these tests; this may be appropriate in cases where the participant is
expected to be at a significantly higher or lower functioning level than would be expected by his/her
grade level/education. This function should be used judiciously and only in cases where the examiner
has prior evidence of lower or higher participant functioning.
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Assign batteries or instruments to a participant
Step 1: Tap Add New Assessment either from a new participant or an existing participant window:
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Once Add New Assessment is tapped, the app will create a new assessment and offer the user an
opportunity to add instruments to that assessment (Add Instruments button). The name of the
assessment defaults to “Assessment X,” where X is a numeral, starting at 1 and moving up
sequentially, depending on how many assessments have been assigned to this participant. Tap the
name of the assessment to edit it.
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Step 2: Select batteries or individual instruments to be added to the assessment from the list of
Available Batteries & Profiles or the list of Available Instruments by tapping Select next to the
instrument’s or battery’s name.
Users can filter the list of available batteries, as well as the list of available instruments by tapping
arrows and making selections from the following categories:
• Measurement Systems
• Domains
• Ages
• Types
Selected instruments will move to the upper part of the screen and will be listed under Selected
Instruments.
NIH Toolbox Touch Screen Tutorial Age 3+ is available and recommended for anyone not
familiar with using an iPad or similar devices. It should be added as the very first instrument in the
assessment.
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NIH Toolbox Emotion Instructions (Adult/Child) should be added immediately before the first
NIH Toolbox Emotion instrument for the given participant. Preset batteries do include appropriate
instructions, so instructions should only be added if the user is not selecting a preset emotion
(adult/child) battery. NIH Toolbox Emotion Instructions (Parent Report) should be added
immediately before the first NIH Toolbox Emotion instrument to be completed by parents about the
given child. Preset batteries do include appropriate instructions, so instructions should only be added if
the user is not selecting a preset emotion (parent report) battery. NIH Toolbox Emotion Instructions
should also be used with NIH Toolbox Pain instruments.
Step 3: Reorder selected instruments, if desired, by dragging them up or down, using the
symbol to the right of the instrument name.
Tap Done in the upper right corner of the screen or tap the arrow in the upper left corner to save your
selections and to return to the previous screen.
Start an Assessment
Upon completing instrument selection, tap Start to launch the assessment.
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At this time, users will be presented either with the assessment launch screen
or with one or more Error or Warning messages alerting users about problems with their assessment.
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Error messages inform users about problems that prevent them from launching the assessment.
Users need to go back to the participant information screen and fix those problems before the
assessment can be started.
Warning messages inform users about missing information or characteristics of the assessment
that users may want to revise before starting. It is possible either to go back to the New Assessment
screen and change them or to launch the assessment without making changes.
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Pause, Skip, Stop
An assessment can be paused at any time after launch.
Step 1: Put two fingers on the screen and rotate one of them clockwise as if making a half-circle on
the screen.
Step 2: Enter the administrator’s passcode that was set up when the app was first launched.
Step 3: Select from the 3 options presented on the screen:

• Resume Instrument
• Skip Instrument
• Stop Assessment
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Different instruments may behave differently if “Resume Instrument” or “Stop Assessment” is selected.
In most cases, users will be taken back to where they were before pausing the assessment. In some
cases (e.g., timed tests), users will be taken back to the beginning of the instrument. In select cases, an
instrument may not be restarted once paused. Detailed rules for each test are available in Appendix 3.
If “Skip Instrument” is selected, users will be asked the reason for skipping:
• Safety Exclusion
• Participant/Respondent Refused
• No Time
• Physical Limitations
• Communication Problems
• Language Barrier
• Equipment Failure
• Ineligible
• Participant Ill/Emergency
• Target Respondent Unavailable
• Other
Once the reason that best describes why the instrument was skipped is selected, users will be taken to
the beginning of the next instrument, or the end of the assessment, if this was the last instrument in
their assessment. If “Other” is selected, users will be taken to a text screen where they will be required
to enter another reason and then allowed to skip the instrument.
If “Stop Assessment” is selected, users will be asked the reason for stopping:
• Safety Exclusion
• Participant/Respondent Refused
• No Time
• Physical Limitations
• Communication Problems
• Language Barrier
• Equipment Failure
• Ineligible
• Participant Ill/Emergency
• Target Respondent Unavailable
• Other
Select the reason that best describes why the assessment is being stopped and proceed to the main
screen of the app. If “Other” is selected, users will be taken to a text screen where they will be required
to enter another reason and then allowed to stop the assessment.
If an instrument is paused, skipped, or stopped, this information is recorded in the data export along
with the reason indicated.
Stopped assessments can generally be resumed, but there are exceptions for specific instruments, as
for pausing. Detailed rules for each test are available in Appendix 3.
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View Existing Participants
If the participant was previously created using the NIH Toolbox app on this iPad, you may also locate
him/her by tapping Search Participants at the top right corner of the black part of the screen.
Once the participant is located, tap their Identifier or Name to open their record.
Tap the arrow to the left of the Identifier to view/edit participant’s information.
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Editing Existing Participants
Please note:
- Editing the top section of participant information will affect all assessments (i.e., completed
assessments, started but not yet completed, and assessments that have not yet been started). If you
make changes to the bottom section of participant information these changes will only be applied to
assessments that have not yet been started.
- If you edit participant information, this change may trigger the rescore of existing data.
Once all the information is complete, return to the previous screen by tapping <Done> or the arrow at
the screen’s top left.
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Resume an Assessment
All partially completed and not started (no items administered) assessments may be resumed (though
individual instruments within them may have varying rules – see Appendix 3).
Generate a report
Once an assessment is completed, a simple report can be generated by tapping Report. Reports
contain demographic information and scores for any tests that were given during that specific
assessment.
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Archiving Participants or Assessments
If a participant or assessment has been created, but is not desired in the list of participants or
assessments, the entry can be archived. This may be useful in managing data after demonstration,
training or practice. If a participant or assessment is created in error, the archive function allows the
user to remove it from the visible list.
If a participant or assessment is archived, it does NOT appear in the data exports when they are
generated from within the app. Participants and assessments can be archived, or unarchived, at any
time. If a participant is archived, the assessments that belong to that participant are also archived. If a
participant is unarchived, the assessments that belong to that participant are also unarchived.
To archive a participant:
On the Participants screen, swipe the desired participant to the left. The "Archive" button will appear.
Select “Archive”.
To unarchive a participant:
On the Participants Screen, select “Show all participants” in the lower left corner of the screen.
Archived participants will appear. Select “Unarchive” next to the desired participant.
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To archive an assessment:
On the Participant screen, swipe the desired assessment to the left. The “Archive” button will appear.
Select “Archive”.
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To unarchive an assessment:
On the Participant screen, select “Show all assessments” in the lower left corner of the screen.
Archived assessments will appear. Select “Unarchive” next to the desired assessment.
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B.4.3 Batteries
View Existing Batteries (Preset and Custom)

This is a quick way to view all the batteries available on this iPad and the instruments that comprise
each.
Step 1: Tap the Batteries button.
You can filter which batteries and profiles you want displayed.
If no custom battery has ever been created on this iPad, the Custom Batteries list will be empty.
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Create a New Custom Battery
Step 1: Tap Create New Battery in the upper right corner of the screen.
Step 2: Enter the new battery’s name (required) and select instruments to be included in this battery
from the list of Available Instruments.
Selected instruments will move to the upper part of the screen and be listed under Selected
Instruments.
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Step 3: Reorder the selected instruments by dragging them up or down, using the symbol to
the right of the instrument name.
Tap Done in the upper right corner of the screen or the arrow in the upper left corner to save the
selection and return to the previous screen.
Archiving Custom Batteries

If a battery has been created, but is not desired in the list of Custom Batteries, the entry can be
archived. This may be useful in managing data after testing, training or practice. If a battery is created
in error, the archive function allows the user to remove it from the visible list.
Batteries can be archived, or unarchived, at any time.
30
To archive a battery:
On the Batteries & Profiles Screen, swipe

the desired battery to the left. The orange
“Archive” button will appear. Select
“Archive”.
To unarchive a battery:
On the Batteries & Profiles Screen, select

“Show all custom batteries” in the lower left
corner of the screen. Archived batteries will
appear. Select “Unarchive” next to the
desired battery.
31
B.4.4 Export Data
The Export Data button allows the user to export data collected on a given iPad. At any point when
export is selected, it will contain all the data cumulatively collected on that iPad. There are four options
to transfer data files from the iPad to another device (i.e., computer connected to a backup server): e-
mail, iCloud drive, configurable web address and file sharing via iTunes (hard-wired). Only file sharing
via iTunes is activated by default. To activate the ability to email files, upload them to iCloud or send
them to a configurable web address, please update Data Security in the NIH Toolbox app Settings.
Data security settings can be updated at any time: before or after data files were generated.
There are three steps to exporting data:
Step 1: Select the files to export by using the filtering options.

The default selection will be data that
has not been exported yet. Below are the available filtering options. These include: Export status and
a date range.
To choose a file for export tap “select” to the right of the assessment that is ready for export. All
assessments can be selected by touching the “Select All” option. Assessments that have been
selected for export will show a checkmark instead of the word “select”.
32
Step 2: Select Export Method. When ready to export the select files touch the “Select Export
Method” button in the top right corner of the screen. This will create/update data files for export.
There are 3 types of data files generated here:
• Registration data (contains participant information entered on this iPad)

• Assessment data (contains data for every item administered to every participant on this iPad)
• Assessment scores (contains scores for every instrument administered to every participant on this
iPad)
33
Step 3: Optional: Edit the name of the file by touching anywhere in the text field, clearing the default
file and typing in a new name. The default file name is always: Date Timestamp File Type.
Step 4: Tap one of 4 symbols (envelope, iCloud, iTunes, web).

Option 1: E- mail
To use this option, users need to:
• Set up the Mail app on the iPad. Mail set-up instructions can be accessed here:
https://support.apple.com/en-us/HT201320.
• Activate the ability to email files. Tap/click here or refer to the NIH Toolbox App Settings
section for detailed instructions.
Once both of the above conditions are met, tap the envelope symbol next to the file to be sent via
email. This will create a new email message. Enter the destination address and tap Send. This
message will arrive from the email address that was used when Mail was set up on this iPad.
When emailing the data files, users should exercise caution and only email the data to secure email
accounts (e.g., their institutional email).
Option 2: iCloud drive.
To use this option, users need to:
• Set up iCloud following the instructions at https://www.apple.com/icloud/setup/ios.html.

• Activate the ability to upload data files via iCloud, Tap/click here or refer to the NIH Toolbox App
Settings section for detailed instructions.
34
If iCloud is enabled on the iPad, all of the files generated by this app will be immediately available in the
iCloud Drive linked to the Apple ID used to install the app. These files can be accessed by logging into
iCloud from any browser using the Apple ID associated with the app that generated the files.
Option 3: File sharing via iTunes
After generating files on the Export Data screen, plug the iPad into a computer with the latest iTunes
version 12.7 or later, and launch iTunes. We recommend to use the most up to date version of iTunes
to get latest improvements from Apple.
• In iTunes, when the iPad appears on the top line of icons, click it.
• There is 'Settings' menu right below the name of connected iPad. The very last option is called
'File Sharing'. Select it to get to the list of all installed apps where file sharing can be used.
• On the left panel called 'Apps', click on the NIH Toolbox app. The files that have been shared by
the app will be shown on the right.
• Use the ‘Save To…’ button at the lower right to copy the file(s) from the iPad to the computer
35
Option 4: Configurable web location
This option is intended for use with an existing web location for data centralization. Many research
projects have a data coordinating center with the capability to set up such a system. For more
information, check with your institution’s IT resources.
Under Data Security settings (go to Settings screen), configure the data transfer URL, user ID and
password. Test the connection at the time of set-up, to ensure smooth data transfer.
After generating files on the Export Data screen, select the “web” icon to send files to the configured
location. You will see a success message (“Export To Web. Success!”), or an error message if the file
is not successfully sent to the configured web address.
36
Sample webservice to be used for configuration and reference:
If Export to Web is enabled on the iPad, all of the data generated by this app will be immediately
sent via a web service to the URL set by the user.
Data export to web feature posts .csv files to a web location specified by the app user. Data
export to web security is handled in the form of basic authentication. Web service should be set to
accept basic authentication. Web service implementation should also acknowledge successful transfer
of the file in the form of json object.
- Data upload webservice
o Form action: POST
o Form request parameters:
 upload: optional. Data are attached to this variable.
o Form Response json object format:
{
“error”:error_code, (error code of 0 indicates successfully transfer of file).
“message”:”message” (optional)
}
Sample of web service implementation in .NET (c#):

/***************** BASIC AUTHENTICATION */
if (ctx.Request.HttpMethod == "OPTIONS")
{
ctx.Response.ContentType = "text";
ctx.Response.ContentEncoding = Encoding.UTF8;
ctx.Response.AppendHeader("Content-Length", "0");
ctx.Response.AppendHeader("Connection", "keep-alive");
ctx.Response.AppendHeader("Access-Control-Allow-Origin", "*");
ctx.Response.AppendHeader("Access-Control-Allow-Headers", "Authorization,
Origin, content-type, accept");
ctx.Response.AppendHeader("Access-Control-Allow-Credentials", "true");
ctx.Response.AppendHeader("Access-Control-Allow-Methods", "OPTIONS, GET,
POST");
return;
}
if (ctx.Request.Headers["Authorization"] == null)
{
ctx.Response.StatusCode = 401;
ctx.Response.AppendHeader("WWW-Authenticate", "Basic");
return;
}
//validate authentication
if (!Authenticate.ValidateRequest(ctx.Request.Headers["Authorization"].ToString()))
{
return;
37
}
//save file
if (ctx.Request.HttpMethod.ToUpper() == "POST")
{
try
{
if (ctx.Request.Files.Count > 0)
{
HttpPostedFile myFile = ctx.Request.Files[0];
if (myFile != null && myFile.ContentLength > 0)
{
Stream fileContents = myFile.InputStream;
string fileName = Path.GetFileName(myFile.FileName);
string path = Path.Combine(ctx.Server.MapPath("~/UploadedData"),
fileName);
myFile.SaveAs(path);
ctx.Response.ContentType = "application/json";
ctx.Response.Write("{\"error\":\"0\"}");
return;
}
}
else
{
return;
}
}
catch (Exception e)
{
return;
}
}
Data Safeguards
Data stored on this iPad are protected by a number of safeguards. These include:
1. The passcode set for this iPad
2. The passcode set for the NIH Toolbox app
3. Requiring the administrator to enter the app passcode at the end of an assessment, before
returning to the home screen
iCloud Security and Privacy policies can be found here: https://support.apple.com/en-us/HT202303
(Internet connection is required to use this link).
38
B.4.5 NIH Toolbox App Settings
• View and apply for Access to Cognition tests

• View subscription information (e.g., how much time is left on the subscription)
o Manage Your Subscription (re-directs to subscription management subscription section
of iPad’s settings. View subscription info, edit and cancel subscription)
• View NIH Toolbox app Terms & Conditions
• Change the app data security settings (enable/disable data export via email and iCloud)
• View FAQs
• View diagnostic information that may be needed when contacting Support
• Change the app passcode
To change the data security settings, tap on Data Security, then update the settings:
39
To return to Data Export instructions tap/click here.
Data Base Back Up
You may be asked to make a backup of your database to support troubleshooting and diagnosis of
issues with this app. The procedure for backing up your data is as follows:
1. Select Settings on the main menu
2. Select Data Security. You may be prompted to enter your passcode.
3. Turn on the toggle labeled Export Database On Next Launch.
4. Press the home button to leave the app.
5. Re-launch the app.
6. Launch iTunes on your computer.
7. Connect your iPad to a computer using a USB cable.
8. Select your iPad in iTunes (near the top left of the iTunes main window).
9. Select Apps at the left side of the screen.
10. Scroll to the bottom of the screen to the section titled File Sharing.
11. Find this app in the list of apps that support File Sharing and select it.
12. In the list of Documents on the right side of the screen you will see three files including todays
date, for example, Backup-2017-03-01 12:00:00.sqlite, Backup-2017-03-01 12:00:00.sqlite-shm,
and Backup-2017-03-01 12:00:00.sqlite-wal. Select these files and copy them to your computer
by clicking the Save To... button at the bottom right of the Documents area.
As a reminder this backup is for troubleshooting and diagnostic purposes. Backups may not be
restored.
There is no need to turn off the Export Database On Next Launch feature. After a single backup is
completed this feature is automatically turned off
40
B.4.6 Audit Logs
There are two Audit Logs available for a user: the Participant Audit Log and the Rescore Audit Log.
These audit logs can be used to identify all records that have been changed and where those changes
occurred.
Participant Audit Log - contains audit entries identifying when a participant snapshot is first created and
when a participant snapshot is modified. It creates a record of the demographic field values before and
after the edits (i.e., old and new demographic data).
Participant audit logs are sorted by PIN, DateCreated and DateModified with the latest (rescored)
record on top and the “before-rescore” record under it.
Rescore Audit Log – includes changes related to any rescoring of data (old and new updated scores).
This audit log includes records for every measure (instrument) affected by scoring adjustment
functionality and/or rescoring of data caused by changes made to demographic information (i.e.,
“demographic rescore”).
This Audit log is sorted by first, PIN and next, Measure/Instrument name. All instrument-level records
are displayed in pairs: the most recent record on top and the “before-rescore” record underneath it.
Composite scores, however, are only included in rescored (new) records.
The Rescore Audit log is not designed to be used in analysis, but as a record of the changes in scores
that were made 1) during the automatic rescoring procedures that were performed in order to improve
equivalency between the web platform and the iOS app; and/or 2) due to the demographic rescore
caused by editing the participant information for a participant with completed assessments. When
reviewing the audit log please note that you will see BOTH the old data and the new rescored data.
The records are paired, with the new, rescored data on top and the old record directly underneath. The
only exception being the rescored composite scores, where you will only find the new rescored records
(v1.1) in the Rescore audit log.
The “Audit Logs” section can be found on the Help & Support screen. Both audit log files (“Participant
Audit Log.csv” and “Rescore Audit Log.csv”) have the following export options: Email, upload to iCloud,
and upload to iTunes. However, “Email” and “upload to iCloud” options are disabled by default. Users
can enable those options via the Data Security section of Settings screen.
For additional information, please see FAQ in the apps.
41
Administering NIH Toolbox
This section contains information about each of the four NIH Toolbox domains: Cognition, Emotion,
Motor and Sensation, as well as descriptions of individual instruments, the equipment and materials
needed for their administration, and age-specific instructions for administering them.
It is recommended that the iPad be placed in a case both for its protection and so that the angle of the
iPad can be placed at multiple positions, to ensure participant comfort. Positioning the iPad so that it is
at an angle of about 60 degrees from the table works best. However, if that setup is not effective for the
participant, the examiner should adjust the angle so that it is most comfortable, while still being easily
visible and accessible to touch. Placing the iPad flat on the table is generally not recommended.
Please note that selected tests (e.g., visual acuity) require that the iPad be placed perpendicular to the
table and at eye level for the participant; using an iPad “easel” or something similar may be used for
this and all other tests if preferred. See Appendix 4 for more information on suggested equipment.
When an examiner administers an instrument to a participant within the app, the first screen they
will see is a title screen that contains the instrument name or a shortened version of the name. Please
note that the name displayed on this screen often does not exactly match the full name of the
instrument displayed when the user/examiner is selecting measures to be administered as part of an
assessment. Appendix 5 contains a key to these abbreviations. The first column in the appendix shows
the title screen as it is displayed at the start of the instrument, and the second column gives the
corresponding full name of the instrument as it appears for selection elsewhere in the app.
A detailed list of equipment and materials needed to administer the entire NIH Toolbox can be
found in Appendix 4.
42
C.1 NIH Toolbox Touch Screen Tutorial
NIH Toolbox Touch Screen Tutorial 3+ is available and recommended for anyone not familiar with
using an iPad or similar device. It is particularly useful for young children and older adults who may
need reassurance that they are able to complete the assessment competently. If used, it should be
added as the very first instrument in the assessment.
Description
This series of screens is designed to help participants to use the iPad and specifically the touch screen.
To help the participant get comfortable with the touch screen, the examiner may want to demonstrate,
move the participant’s finger, or, in other ways, encourage the participant to do the required actions.
The task is introduced with the Title Screen: NIH Toolbox Touch Screen Tutorial 3+. At the bottom of
the screen is a button Touch and Hold Here to Continue. Touch and hold that button to begin the
tutorial.
Read the next screen to the participant: First, you will practice touching pictures on the screen.
When finished reading, touch the button at the bottom of the screen that says: Touch and Hold Here
to Continue.
Read: Touch the flower on the screen. After participant touches the flower, the next screen appears.
If participant does not touch the flower, the flower remains on the screen.
Read: Good! Now we are going to do some more. Touch the button at the bottom of the screen that
says: Touch and Hold Here to Continue.
Read: Now, touch the star. After participant touches the star, the next screen appears. If participant
does not touch the star, the star remains on the screen.
Read: Good! Let’s do one more. Touch the button at the bottom of the screen that says: Touch and
Hold Here to Continue.
Read: Now, touch the apple. After participant touches the apple, the next screen appears. If
participant does not touch the apple, the apple remains on the screen.
Read: Good! Now, you are ready to continue. When finished reading, touch the button at the bottom
of the screen that says: Touch and Hold Here to Continue.
43
C.2 Cognition Domain
Cognition refers to the mental processes involved in gaining knowledge and comprehension such as
thinking, knowing, remembering, judging, and problem solving. These higher-level functions of the brain
encompass language, imagination, perception, and the planning and execution of complex behaviors.
There is an Early Childhood Cognition Battery designed for ages 3-6 and a Cognition Battery for
ages 7-85, or you can create a custom battery.
Early Childhood Cognition Battery

NIH Toolbox instrument development focused special attention on assessing young children to ensure
that all tests and surveys given would be developmentally appropriate for ages 3-6. The Early
Childhood Cognition Battery includes instruments to assess the following constructs: Attention,
Episodic Memory, Executive Function and Language.
Cognition Battery
The NIH Toolbox Cognition Battery is recommended for ages 7+. It consists of instruments that assess
the following constructs: Executive Function, Attention, Episodic Memory, Language, Processing
Speed, and Working Memory.
Cognition instruments are not available for immediate use in the app. To access these
instruments, a user must submit a short application for approval. Users who have been approved to use
NIH Toolbox Cognition instruments in Assessment Center (web-based version of NIH Toolbox) will be
approved without submitting any additional information. New users will be asked to submit credentials
demonstrating they have the appropriate knowledge, skills, training and experience to responsibly use
NIH Toolbox measures, or are working under the supervision of someone qualified to use those
measures.
Application instructions can be found in the app, when touching the “lock” icon next to any cognition
instrument. Once approved, a user will receive a code via email to enter on their iPad, and instruments
can then be immediately administered. The user will also receive other restricted materials at that time
(e.g., NIH Toolbox Oral Reading Recognition Test Pronunciation Guide and the NIH Toolbox List
Sorting Working Memory Examiner Answer Sheet).
For more information about access to cognition instruments, please contact cognition@nihtoolbox.org.
Cognition
Battery Definition
Constructs
The capacity to plan, organize and monitor the execution of behaviors that
are strategically directed in a goal-oriented manner. The NIH Toolbox
Executive focuses on two components: 1. Inhibition of automatic response tendencies
that may interfere with achieving a goal, which is measured by the NIH
Function
Toolbox Flanker Inhibitory Control and Attention Test; and 2. Set shifting, or
the capacity for switching among multiple aspects of a strategy or task,
which is measured by the NIH Toolbox Dimensional Change Card Sort Test
44
The allocation of one’s limited capacities to deal with an abundance of
Attention environmental stimulation. It is measured by the NIH Toolbox Flanker
Inhibitory Control and Attention Test.
The acquisition, storage and retrieval of new information. It involves
Episodic
conscious recollection of information learned within a context. It is
Memory
measured by the NIH Toolbox Picture Sequence Memory Test.
A set of mental processes that translate thought into symbols (words,
gestures) that can be shared among individuals for purposes of
communication. The NIH Toolbox focuses on two aspects of language: 1.
Language Vocabulary knowledge, measured by the NIH Toolbox Picture Vocabulary
Test; and 2. Oral reading (decoding) skills, measured by the NIH Toolbox
Oral Reading Recognition Test.
The amount of time it takes to mentally process a set amount of

Processing information, or the amount of information that can be processed within a
Speed certain unit of time. It is a measure that reflects mental efficiency, and is
measured by the NIH Toolbox Pattern Comparison Processing Speed Test.
Working The capacity of an individual to hold information in a short-term buffer and
manipulate the information. It is measured by the NIH Toolbox List Sorting
Memory
Working Memory Test.
Time to
Cognition Battery Instruments Ages Administer
(minutes)
NIH Toolbox Picture Vocabulary Test 3-85* 4
NIH Toolbox Flanker Inhibitory Control and Attention Test 3-85* 3
NIH Toolbox List Sorting Working Memory Test 7-85 7
NIH Toolbox Dimensional Change Card Sort Test 3-85* 4
NIH Toolbox Pattern Comparison Processing Speed Test 7-85 3
NIH Toolbox Picture Sequence Memory Test 3-85* 7
NIH Toolbox Oral Reading Recognition Test 7-85 3
*Part of the NIH Toolbox Early Childhood Cognition Battery
In addition to the instruments available as part of the cognition battery (which may also be administered
individually), there are Supplemental instruments that may be administered to participants – either in
addition to or, more likely, in lieu of cognition battery instruments assessing the same construct. These
supplemental instruments generally extend the age range or the “floor” of these constructs downward.
More information about these instruments is available below.
Time to
Cognition Supplemental Instruments Ages Administer
(minutes)
NIH Toolbox Pattern Comparison Processing Speed Test 3-6 3
NIH Toolbox Flanker Inhibitory Control and Attention Test
3-7 7
with Developmental Extension (Experimental)
NIH Toolbox Dimensional Change Card Sort Test with 3-7 8
Developmental Extension (Experimental)
NIH Toolbox List Sorting Working Memory Test 3-6 7
NIH Toolbox Oral Symbol Digit Test 8-85 3
NIH Toolbox Auditory Verbal Learning Test (Rey) 8-85 3
45
The “Time to Administer (minutes)” column gives users an idea of how long each test might take;
however, please note that testing times could vary based on how prepared the test administrator is
going into the session, individual differences among participants, and/or other unplanned activities that
may occur during testing.
C.2.1 NIH Toolbox Picture Vocabulary Test
The NIH Toolbox Picture Vocabulary Test is a measure of receptive vocabulary administered in a
computer-adaptive test (CAT) format.
Equipment and materials needed:

I. iPad
The participant is presented with four pictures on the iPad screen and an audio recording saying a
word. The participant is instructed to touch the picture that most closely shows the meaning of the
word. After the participant makes a choice, another set of pictures automatically appears with the next
item and associated audio file.
Because the test uses a variable-length CAT, some participants see fewer items than others. The
specific words presented depend on the participant’s performance. The number of items presented
depends on age and performance; for most participants, the measure will last approximately 5 minutes
and will contain about 25 items. The computer will administer each item one by one, in an untimed
fashion, until the test is completed.
The test uses age (for participants younger than 18) and education (for participants 18 and older) to
determine which items it initially presents. There is, however, an override in the participant information
screen. If an examiner feels that a participant should begin the test at a level higher or lower than that
determined by his/her education and age, the examiner should use this feature. Using the override may
shorten the test. It is important to note that even if the override is not used, the test will eventually
arrive at the same score whether the examiner used the override or not.
General Instructions:
1. The opening/introductory instructions and the introductions to the test items are printed on the iPad
screen and are read to the participants; all other instructions are pre-recorded.
2. The introduction and test instructions differ somewhat for younger and older participants. The
required version will appear automatically for the examiner to read.
3. Before beginning, make sure the volume is loud enough so that participants can hear the pre-
recorded feedback and the presentation of the words.
4. If the participant says he/she does not understand the word after several repetitions, the examiner, if
present, may say the word one more time.
If there is an examiner present and a participant has difficulty touching the screen, the participant
may point and the examiner can touch the screen. In this case, the examiner should say
something like the following to the participant: You can point to your choice and then I will
touch the screen for you.
46
C.2.1.1 NIH Toolbox Picture Vocabulary Test Instructions Age 3+
The task is introduced with the Title Screen: NIH Toolbox PVT 3+. At the bottom of the screen is a
button Touch and Hold Here to Continue. Touch and hold that button to begin the test.
The next screen is slightly different for participants ages 3-6 and those ages 7+. The two screens are
printed below.
Ages 3-6:
Say: Let’s look at some pictures. You’ll hear a word and see four pictures on the screen. Touch
the picture that means the same as the word that was said. Some words will be easy and some
will be harder. Answer as best as you can. If you need to hear a word again, I can play it again.
If you think you made a mistake and want to change your last answer, I can bring back that word
and pictures. Are you ready to play?
When participant is ready, touch button that says Touch and Hold Here to Continue.
Ages 7+:
Say: You are going to be asked the meaning of some words. For each item, you will hear a word
and see four pictures on the screen. Touch the picture that you think best matches the meaning
of the word that was said. If you are not sure, make your best guess. If you need to hear the
word again, touch the button that has a picture of an EAR, also called the PLAY AGAIN button.
After you touch a picture, you will hear a new word and see more pictures.
You will keep hearing words and touching pictures until you are done. If you want to change
your last answer, touch the button with the HAND that says GO BACK. The pictures you just
saw will reappear and you will hear the word again. Touch your choice, and then more words
and pictures will appear. Tell me when you are ready to start.
Practice item 1:
An audio recording says: Let’s try one for practice: Banana. Touch the picture of Banana.
If correct, the audio recording says: That’s right! The program will automatically go to the next practice
item.
If incorrect, the Banana picture will light up and an audio recording will say: This is a banana. Let’s try
again.
The examiner should allow the participant up to three chances to answer this practice item correctly.
After three unsuccessful attempts by the participant, the examiner should touch the picture of the banana
and say: This is a banana. The next practice item will appear automatically.
Practice item 2:
An audio recording says: Let’s try another one: Spoon. Touch the picture of Spoon.
If correct, an audio recording says: That’s right!
47
If incorrect, the Spoon picture will light up and an audio recording will say: This is a spoon. Let’s try
again.
The examiner should allow the participant up to three chances to answer this practice item correctly.
After three unsuccessful attempts by the participant, the examiner should touch the picture of the spoon
and say: This is a spoon.
The introduction to the test items will appear automatically.
Test items
The introductory screen to the test items is slightly different for participants ages 3-6 and those ages 7+.
The two screens are printed below.
Ages 3-6:
Read: Now, let’s try some more. Remember, you will hear a voice say a word and then you will
see four pictures. One of the pictures will show what the word means. Touch that picture and you
will hear a new word and see four more pictures. Any questions?
Ages 7+:
Read: Now, you’re going to do some more. Remember, you will hear a word and then you will
see four pictures. One of the pictures will show what the word means. Touch that picture and
you will hear a new word and see four more pictures. Again, touch the picture that shows what
the word means. If you don’t know, make your best guess. Any questions?
An audio recording will introduce each word with the instructions: Touch… (for participants ages 3-6)
and just the Word (for participants ages 7+). The items will continue in this format until the test is
completed.
Remember: If a participant has difficulty touching the screen, he/she may point and the examiner
can touch the screen. In this case, the examiner should say something like the following to the
participant: You can point to your choice and then I will touch the screen for you. If the
participant says that he/she does not understand the word after several repetitions, the examiner
may say the word ONCE MORE.
48
C.2.2 NIH Toolbox Flanker Inhibitory Control and Attention Test
The NIH Toolbox Flanker Inhibitory Control and Attention Test is a measure of inhibitory control and
attention. The Flanker requires the participant to focus on a particular stimulus while inhibiting attention
to the stimuli flanking it.
• iPad
• Home base
Detailed information on equipment and materials needed for all tests can be found in Appendix 4.
Younger participants first see a fish flanked by two other fish on each side. If they perform well enough,
they continue to a version with an arrow flanked by other arrows on each side.
Older participants (ages 8-85 years) are always presented with arrows instead of fish.
All participants are instructed to choose one of two buttons on the screen that corresponds to the
direction in which the MIDDLE fish or arrow is pointing.
On congruent trials, all the fish or arrows are pointing in the same direction. On incongruent trials, the
flanking fish or arrows are pointing in the opposite direction of the middle fish or arrow. Congruent and
incongruent trials are mixed.
The word middle appears on the screen for all participants; for younger participants (ages 3-11), an
audio recording also says "MIDDLE," to remind participants where to focus (a star in the middle of the
screen).
All the instructions are on the iPad screen. The examiner reads them to and/or with the
participant and points out the relevant aspects of the stimuli on the screen.
There are two versions of this measure for ages 3-7. The first is the standard NIH Toolbox Flanker test
for ages 3-7. The second is an experimental version (with “developmental extension,” or DEXT) that
was designed to extend the range of assessment downward, for those participants who have difficulty
understanding the standard task. Both versions yield a score for the standard measure, and the DEXT
version provides simple raw scores and percentages for the experimental items.
Standard administration (all ages):
Practice items
In this version, all participants are first presented with four practice trials. If the participant responds
incorrectly, an audio recording provides feedback and highlights the correct choice. Similarly, a
separate audio file plays each time the participant gets a practice item correct. Participants must get at
least three out of four practice trials correct to advance to the test items. If these participants get fewer
than three out of four practice trials correct, they can complete up to two more sets of four practice
trials, with the same cutoff to advance to the test trials.
If the participant does not respond after five seconds to a practice trial, prompt him/her to do so by
saying: Choose one of the buttons.
49
Test Trials
One block of 20 test trials is used for all participants; 3-7-year-olds have fish stimuli and ages 8+ have
arrow stimuli.
If a participant ages 3-7 misses no more than one congruent and one incongruent item on the fish trials,
he/she will also receive a set of 20 arrow trials.
Training for home base precedes the arrow trials for both the 3-7 and 8+ year olds.
Developmental Extension (DEXT ages 3-7):

In this version, participants are given five practice trials. If the participant responds incorrectly, an audio
recording provides feedback and highlights the correct choice. Similarly, a separate audio file plays
each time the participant gets a practice item correct.
A participant must succeed in 4 out of 5 practice trials to move on.
If a participant does succeed, the test administration continues in the same manner as the standard
administration described above.
If he/she does not succeed on the practice trials, he/she is directed to the developmental extension of
this measure. In addition, participants will be directed to the developmental extension if they do not
achieve at least 75% correct on congruent fish trials OR at least 25% correct on incongruent fish trials.
The logic underlying the developmental extension is detailed in the test instructions (FLANKER 3-7
DEXT).
Age-specific test instructions:

NIH Toolbox Flanker Inhibitory Control and Attention Test Instructions Ages 3-7
NIH Toolbox Flanker Inhibitory Control and Attention Test Instructions Ages 3-7 with Developmental
Extension (DEXT)
NIH Toolbox Flanker Inhibitory Control and Attention Test Instructions Ages 8-11
NIH Toolbox Flanker Inhibitory Control and Attention Test Instructions Ages 12+
50
C.2.2.1 NIH Toolbox Flanker Inhibitory Control and Attention Test Instructions Ages 3-7
This table outlines the item content read by as well as the actions for the examiner.
iPad screen written content Examiner (E) Action
Title Screen NIH Toolbox FL 3-7 E touches and holds button to

continue.
PRACTICE Here is a Fish! E points to screen; then
Introduction This is the TAIL -> [fish] <- This is the MOUTH. touches and holds button to
The fish is pointing this way, the same way the fish continue.
is swimming.
Here the MIDDLE fish is circled. Can you point to Child points; E touches and
the MIDDLE fish? holds button to continue.
Where is the MIDDLE fish here? Child points; E touches and
holds button to continue.
Look at all the fish!!! The fish in the MIDDLE is E touches and holds button to
hungry. continue.
To feed the MIDDLE fish, choose the button that E demonstrates using index
matches the way the MIDDLE fish is pointing. finger to touch arrow button.
Here the MIDDLE fish is pointing this way, so I’ll E demonstrates touching
choose this button. arrow button.
If the MIDDLE fish is pointing this way, choose this E demonstrates touching
button. arrow button.
Sometimes all the fish point the same way. E points; then chooses arrow
Sometimes the MIDDLE fish points a different way, button.
like this: [incongruent fish].
You should always choose the button that matches
the way the MIDDLE fish is pointing. You will hear
the word MIDDLE to remind you.
Here, the MIDDLE fish is pointing this way, so I’ll E points; then chooses arrow
choose this button. button.
Here, the MIDDLE fish is pointing this way, so I’ll E points; then chooses arrow
choose this button. button.
Transition to Now you try. E reads screen; then touches

practice items Keep your eyes on the star in the middle of the and holds button to continue.
screen.
Practice Items 4 practice items
set 1
More practice, if Let’s practice some more. If the MIDDLE fish is E points; then chooses arrow
less than 3 out pointing this way, choose this button. button.
of 4 correct on
set 1
If the MIDDLE fish is pointing this way, choose this E points; then chooses arrow
button. button.

more practice Keep your eyes on the star in the middle of the and holds button to continue.
items screen.
set 2
More practice, if Let’s practice some more. If the MIDDLE fish is E points; then chooses arrow
less than 3 out pointing this way, choose this button. button.
of 4 correct on
set 2
51
If the MIDDLE fish is pointing this way, choose this E points, then chooses arrow
button. button.
more practice Keep your eyes on the star in the middle of the and holds button to continue.
items screen.
set 3
Test ends, if less than 3 out of 4 correct on set 3
Test items Now you’re ready to do this without me. E reads screen; then touches
transition Keep your eyes on the star in the middle of the and holds button to continue.
screen.
Test items 20 test items (fish)
Test ends, if
less than 90%
success on fish
Home Base Now you will do the same thing, but you will see E reads screen and points to
training, if 90% arrows instead of fish. But first we are going to the home base; then touches
or greater learn about Home Base. This is your Home Base. and holds button to continue.
success on fish Put your finger on the Home Base and wait for the
next picture.
In this game, put your finger back on Home Base
after each answer.
Like before, choose the button that matches the E points; then chooses arrow
way the middle arrow is pointing. button.
Sometimes all the arrows will point the same way. E reads screen, points to the
Sometimes the middle arrow will point a different arrows, and demonstrates
way. touching arrow button.
You should always choose the button that matches
the way the MIDDLE arrow is pointing.
More test items Now you try. E reads screen; then touches
(arrows) Keep your eyes on the star in the middle of the and holds button to continue.
screen.
Remember; put your finger back on Home Base
after you answer.
20 test items (arrows)
52
C.2.2.2 NIH Toolbox Flanker Inhibitory Control and Attention Test Instructions Ages 3-7
with Developmental Extension (DEXT)
This table outlines the item content read by and the actions to be performed by the examiner and the
child.
iPad screen written content Child (C) & Examiner (E) Actions
Title Screen NIH Toolbox FL 3-7 DEXT E touches and holds button to continue.
PRACTICE Here is a Fish! E points to screen; then touches and

Introduction holds button to continue.
This is the TAIL -> [fish] <- This is the
MOUTH.
The fish is pointing this way, the same

way the fish is swimming.
Here the MIDDLE fish is circled. Can Child points; E touches and holds button
you point to the MIDDLE fish? to continue.
Where is the MIDDLE fish here? Child points; E touches and holds button
to continue.
Look at all the fish!!! The fish in the E touches and holds button to continue.
MIDDLE is hungry.
To feed the MIDDLE fish, choose the E demonstrates using index finger to
button that matches the way the touch arrow button.
MIDDLE fish is pointing.
Here the MIDDLE fish is pointing this E demonstrates touching arrow button.
way, so I’ll choose this button.
If the MIDDLE fish is pointing this way, E demonstrates touching arrow button.
choose this button.
Sometimes all the fish point the same E points; then chooses arrow button.
way. Sometimes the MIDDLE fish points
a different way, like this: [incongruent
fish].
You should always choose the button

that matches the way the MIDDLE fish
is pointing.
Here, the MIDDLE fish is pointing this E points; then chooses arrow button.
Here, the MIDDLE fish is pointing this E points; then chooses arrow button.
Transition to Now you try. E reads screen; then touches and holds
practice items button to continue.
53
Keep your eyes on the star in the

middle of the screen.
Practice items 5 practice items
If less than 4 out Moves to developmental extension

of 5 correct
Test items Now you’re ready to do this without me. E reads screen; then touches and holds
transition button to continue.
middle of the screen.
Test items 20 test items (fish)
If < 9 congruent Moves to developmental extension

trials correct OR
< 2 incongruent
trials correct
If correct on >= Now you will do the same thing, but you E reads screen and points to the home
11 congruent will see arrows instead of fish. But first base; then touches and holds button to
AND on >= 7 we are going to learn about Home Base. continue.
incongruent (no This is your Home Base.
more than 1
incorrect of Put your finger on Home Base and wait
each) for the next picture.
In this game, put your finger back on

Home Base after each answer.
Like before, choose the button that E points; then chooses arrow button.
matches the way the middle arrow is
pointing.
Sometimes all the arrows will point the E reads screen, points to the arrows, and
same way. Sometimes the middle demonstrates touching arrow button.
arrow will point a different way.
You should always choose the button

that matches the way the MIDDLE arrow
is pointing.
More test items Now you try. E reads screen; then touches and holds
(arrows) button to continue.
middle of the screen. Try to answer as
fast as you can. Remember: Put your
finger back on Home Base after you
answer.
20 test items (arrows)
54
Developmental Extension
DEXT Screen 1 – Let’s try some more! Here is a Fish. E reads screen and then E touches right
Demo Trial 1 This Fish is HUNGRY! To feed the arrow. Screen won’t advance until
HUNGRY Fish, we have to touch the correct arrow is touched. When correct
button pointing the same way that the arrow is touched, bubbles sound plays
HUNGRY Fish is swimming (Right and iPad says: Mmm, thank you.
button is flashing after 5 seconds)
Touch and hold here to continue screen E touches and holds button to continue.
appears.
DEXT Screen 2 – Now it’s your turn. Feed the HUNGRY E reads screen. Child touches an arrow.
Practice Trial 1 Fish by touching the button that points If incorrect, iPad says: Let’s try again.
the same way the HUNGRY Fish is Repeats until correct arrow is touched. If
swimming. correct, bubbles sound plays and iPad
says: Mmm, thank you.
Touch and hold here to continue E touches and holds button to continue.
appears on screen.
DEXT Screen 3- – Let’s try some more. E reads screen; then E touches and
Transition holds button to continue.
DEXT Screens 4- 5 practice items with fish bowl on screen

8
DEXT Screen 9 – Here’s another HUNGRY Fish. We E reads screen and then E touches left
Demo Trial 2 don’t see the food, but it’s still there. I arrow. Screen won’t advance until
am going to touch the button pointing correct arrow is touched. When correct,
the same way the hungry fish is bubbles sound plays and iPad says:
swimming. Mmm, thank you.
appears on screen.
DEXT Screen 10 – Now it’s your turn. Touch the button E reads screen. Child touches an arrow.
Practice Trial 2 that’s pointing the same way this Fish is
swimming. If incorrect, iPad says: Let’s try again.
Repeats until correct arrow is touched.
If correct, bubbles sound plays and iPad

says: Mmm, thank you.
appears on screen.
DEXT Screen 11 – Let’s try some more! E reads screen and then E touches and
DEXT Screens 5 practice items without fish bowl If either arrow is touched, bubbles sound
12-16 plays. If neither arrow is touched, moves
to new item after 10 seconds.
If less than 4 of 5 correct on screens 12-16, test is discontinued.
55
Developmental Extension
If 4 or more correct, test continues to Screen 17
DEXT Screen 17 – Look at this! The hungry Fish has E reads screen and then E touches right
Demo Trial 3 friends. These fish friends are NOT arrow. When correct arrow is touched,
hungry, only the MIDDLE Fish is hungry. bubbles sound plays and iPad says:
Watch me while I touch the button that is Mmm, thank you.
pointing the same way that the hungry
MIDDLE Fish is swimming!
appears on screen.
DEXT Screen 18 – Now it’s your turn to feed the hungry E reads screen. C touches an arrow. If
Practice Trial 3 MIDDLE fish. I want you to touch the incorrect, iPad says: Let’s try again.
button pointing the same way the Repeats until correct. If correct, bubbles
MIDDLE Fish is swimming. sound plays and iPad says: Mmm,
thank you.
appears on screen.
DEXT Screen 19 – Now you try. E reads screen and then E touches and
Keep your eyes on the star in the middle
of the screen.
DEXT Screens 5 items (Spacing/Size/Color block) If either arrow is touched, bubbles sound
on to new item after 10 seconds.
DEXT Screens 5 items (Size/Color block) If either arrow is touched, bubbles sound
DEXT Screens 5 items (Color block) If either arrow is touched, bubbles sound
DEXT Screens 5 items (Toolbox Flanker Fish block) If either arrow is touched, bubbles sound
After screen 39, DEXT ends.
C.2.2.3 NIH Toolbox Flanker Inhibitory Control and Attention Test Instructions Ages 8-
11
56
Title Screen NIH Toolbox FL 8-11 E touches and holds

button to continue.
Home Base In this task, you will see a row of arrows pointing different ways. E reads screen and
Introductions But first, we are going to learn about Home Base. This is your points to the home
Home Base. Put your finger on Home Base and wait for the base; then touches and
next picture. holds button to
continue.
Practice You will see a row of arrows. You should choose the button E points to left arrow
Introduction that matches the way the MIDDLE arrow is pointing. and demonstrates
touching the correct
arrow.
If the MIDDLE arrow is pointing this way, choose this button. E demonstrates
touching arrow button.
Sometimes all the arrows will point the same way. Sometimes E reads screen, points
the middle arrow will point a different way, like this [picture of to the arrows, and
incongruent arrows]. You should always choose the button that demonstrates touching
matches the way the MIDDLE arrow is pointing. arrow button.
Transition to Now you try. E reads screen; then

practice items touches and holds
Keep your eyes on the star. Answer as fast as you can button to continue.
without making mistakes.
If you make a mistake, just keep going!
Remember, put your finger back on Home Base after you

answer.

set 1
More practice, if Let’s practice some more. If the MIDDLE arrow is pointing this E reads screen and
less than 3 out way, choose this button. demonstrates touching
of 4 correct on arrow button.
set 1
If the MIDDLE arrow is pointing this way, choose that button. E demonstrates

more practice touches and holds
items Keep your eyes on the star. Answer as fast as you can button to continue.

answer.
57

set 2
set 2
If the MIDDLE arrow is pointing this way, choose that button. E demonstrates

more practice touches and holds
items Keep your eyes on the star. Answer as fast as you can button to continue.

answer.

set 3
Test Items Now you’re ready to do this without me. E reads screen; then
Introduction touches and holds

answer.
Test items 20 items (arrows)
C.2.2.4 NIH Toolbox Flanker Inhibitory Control and Attention Test Instructions Ages 12+

Title Screen NIH Toolbox FL 12+ E touches and holds
button to continue.
Home Base In this task, you will see a row of arrows pointing different ways. E reads screen and
Introductions But first, we are going to learn about Home Base. This is your points to the home
58
Home Base. Put your finger on Home Base and wait for the base; then touches and
next picture. holds button to
continue.
Practice You will see a row of arrows. You should choose the button E points to left arrow
Introduction that matches the way the MIDDLE arrow is pointing. and demonstrates
touching the correct
arrow.
Sometimes all the arrows will point the same way. Sometimes E reads screen, points
the middle arrow will point a different way, like this. You should to the arrows, and
always choose the button that matches the way the MIDDLE demonstrates touching
arrow is pointing. You will see the word MIDDLE to remind you. arrow button.
practice items Keep your eyes on the star. Answer as fast as you can touches and holds
without making mistakes. button to continue.
answer.
set 1
set 1

more practice Keep your eyes on the star. Answer as fast as you can touches and holds
items without making mistakes. button to continue.
answer.
set 2
set 2
more practice Keep your eyes on the star. Answer as fast as you can touches and holds
items without making mistakes. button to continue.
answer.
set 3
59
Test Items Now you’re ready to do this without me. E reads screen; then
Introduction Keep your eyes on the star. Answer as fast as you can touches and holds
without making mistakes. button to continue.
answer.
Test items 20 items (arrows)
60
C.2.3 NIH Toolbox List Sorting Working Memory Test
This task assesses working memory and requires the participant to recall and sequence different
visually and orally presented stimuli. Pictures of different foods and animals are displayed with both an
accompanying audio recording and written text that name the item. The participant is asked to say the
items back to the examiner in size order from smallest to largest.
• iPad
• Bluetooth wireless keyboard
• NIH Toolbox List Sorting Working Memory Examiner Answer Sheet
Setting up Bluetooth Wireless Keyboard:
• Go to the Settings app of the iPad and make sure Bluetooth is turned on.
• Make sure the keyboard is in discovery mode by pressing the round button at the top right end
of the keyboard and the small green light to the left of the button begins flashing.
• Select the Keyboard when it appears on the My Devices list on the iPad.
• When a pop up window appears on the iPad screen, follow the instructions and enter the
required code on the keyboard.
The usual keyboard on the iPad will not work when the external keyboard is working. To turn off
the external keyboard, press the round button at the top right end of the keyboard, move at least
15 meters from the iPad with the keyboard, or touch the “information” button  on the iPad and
touch “forget this device.”
Using the Keyboard
Once the participant answers (gives the list of objects), the examiner types 1 if the response (list) is
correct or 0 if the response (list) is incorrect.
For the practice items, after choosing 1 or 0, the examiner presses the spacebar to move on to the next
item (list of objects). There is feedback presented by the prerecorded voice and repeated trials for
errors.
For the test items, after the examiner chooses 1 or 0, the question: Are you ready? appears on the
screen. The examiner presses the spacebar to move on to the next item (list of objects) after the
participant answers the question affirmatively. The examiner can change an entered response (1 or 0)
prior to pressing the spacebar. Once the spacebar is pressed, the examiner can not go back to the
previous item.
Ctrl + Shift on the Keyboard is equivalent to the gesture used to STOP an administration on the iPad.
Like the iPad, when Ctrl + Shift is entered on the keyboard, a login screen will pop up and ask for the
password of the user who started the assessment. As described earlier, three options will appear:
resume, skip, and stop.
There are two different conditions: 1-List and 2-List.

In the 1-List condition, participants are required to order a series of objects (either food or animals) in
size order from smallest to largest. The test begins with a two object item. The participant must succeed
at one of the first two object items to continue. (See the discontinue rules below).
61
In the 2-List condition, participants are presented both food and animals and are first asked to say the
food objects in size order, and then the animal objects in size order.
In each condition, participants ages 7-85 have two practice items; both items are presented in a “flashing”
mode.
Because the participant answers orally, this measure cannot be self-administered. An examiner must
record on a wireless keyboard whether each response is correct; specifically, after the participant
answers (gives the list of objects), the examiner types 1 if the response (list) is correct or 0 if the response
(list) is incorrect.
For the practice items, after choosing 1 or 0, the examiner presses the spacebar to move on to the next
item (list of objects). There is feedback presented by a prerecorded voice and there are repeated trials
for errors.
For the test items, after the examiner chooses 1 or 0, the question: Are you ready? appears on the
screen. Once confirming that the participant is ready and attending, the examiner presses the spacebar
to move on to the next item (list of objects).
For the examiner, there is a code at the bottom right side of the iPad screen to indicate which item is
being administered. The examiner should use this code to look up the correct response on the NIH
Toolbox List Sorting Working Memory Examiner Answer Sheet, and then score the item using the
keyboard (1 or 0 and pressing the spacebar).
Introduction:
For an item to be marked correct, the participant must name all the stimuli in the correct order without
any intrusions. A participant may change his/her response. It is also acceptable for a participant to
give a synonym for either a food item or an animal. For example, in English, responses such as
these should be marked as correct: puppy for dog, bunny for rabbit, and lamb for sheep.
Several discontinue rules are embedded in the software:
• If a participant does not complete a practice item correctly, the test itself is not administered.
• If a participant has incorrect responses on both parts of a test item, the test condition being
administered (1-List or 2-List) is discontinued.
• If the participant has a score of 1 point as the sum of the two sets of 2-stimulus items (pig-mouse
and bird-cow; banana-watermelon and apple-blueberry) and a score of 0 points on the set of 3-
stimulus items (pumpkin-strawberry-banana and dog-horse-rabbit) in the 1-list condition, the test
is discontinued and the 2-list condition is not administered.
• If the participant has a score of 0 points as the sum of the two sets of 2-stimulus items (pig-mouse
and bird-cow; banana-watermelon and apple-blueberry), the test is discontinued and the 2-list
condition is not administered.
Throughout the test, the examiner may need to remind the participant: It is important to pay
attention to the size of the objects on the screen (not what they may have experienced) when
putting things in size order from smallest to biggest.
If necessary, examiners can provide short breaks between items. It is also acceptable during the 2-List
condition to remind participants of the rules (e.g., tell me the foods first, then the animals).
62
C.2.3.1 NIH Toolbox List Sorting Working Memory Test Instructions Ages 3-6
Before beginning the test, the wireless keyboard should be paired by Bluetooth with the iPad, if this has
not already been done. While administering this measure, the examiner needs to be able to view the
iPad and have the keyboard and Examiner Answer Sheet easily accessible for scoring child responses.
The task is introduced with the Title Screen: NIH Toolbox LS 3-6. To check the Bluetooth connection,
the examiner is asked at the bottom of the page to: Press Spacebar to Continue. Touching the spacebar
begins the test. If the spacebar does not work, try repairing the keyboard or changing the batteries in the
keyboard.
For this age group, each practice item has multiple questions. Letters designate the question (e.g., A, B).
Children have two opportunities to answer each question correctly. If the child does not answer correctly
after two opportunities, the test is discontinued.
1-List Condition
Read the screen: Now, we’re going to look at things that are different sizes. Some of the things are
small and some things are big (use hand gestures). Your job is to tell me what is smallest and
what is biggest. Let’s start by looking at some pictures of animals together. Press Spacebar to
continue.
1-List Practice Item 1:
An audio recording with an accompanying animation says: This is a DOG (examiner points to dog on
screen) and this is a HORSE (examiner points to horse).
Question A: The audio recording continues: Which animal is the smaller animal? If child does not
respond, after 10 seconds, the audio recording says again with animation: Which is smaller, the DOG or
the HORSE?
Correct Response: If child says DOG, examiner presses 1 and then the spacebar. The audio recording
says: Good job. The iPad automatically moves to the next question.
Incorrect Response: If child does not say DOG, examiner presses 0 and then the spacebar. The item
plays again and the audio recording says: Let’s try that again. See, the DOG is smaller than the HORSE
(point out relative sizes using gestures). Now, say the smaller animal. If child says DOG, examiner
presses 1 and then the spacebar. The audio recording says: Good job. The iPad automatically moves to
the next question.
If child does not know smaller animal after two trials, examiner presses 0 and then the spacebar. Test
will be discontinued.
63
Question B: The item plays again and the audio recording says: Now, say the bigger animal.
Correct Response: If child says HORSE, examiner presses 1 and then the spacebar. The audio recording
Incorrect Response: If child does not say HORSE, examiner presses 0 and then the spacebar. The item
plays again and the audio recording says: Let’s try that again. The HORSE is bigger than the DOG
(point out relative sizes). Now, say the bigger animal. If child says HORSE, examiner presses 1 and then
the spacebar. The audio recording says: Good job. The iPad automatically goes to next question.
If child does not know bigger animal after two trials, examiner presses 0 and then the spacebar. Test will
be discontinued.
Read the screen: Now, we are going to do some more. Press spacebar to continue.
An audio recording with an accompanying animation says: This is a RABBIT (point to RABBIT); this is a
SHEEP (point); and this is an ELEPHANT (point).
Question A: The audio recording continues: Say the smallest animal.
Correct Response: If child says RABBIT, examiner presses 1 and then the spacebar. The audio recording
Incorrect Response: If child does not say RABBIT, examiner presses 0 and then the spacebar. The item
plays again and the audio recording says: Let’s try that again. The RABBIT is smaller than the SHEEP
(point), and the RABBIT is smaller than the ELEPHANT (point). The RABBIT is the smallest animal. Now
you say the smallest animal. If child says RABBIT, examiner presses 1 and then the spacebar. The audio
recording says: Good job. The iPad automatically moves to the next question.
If child does not know smallest animal after two trials, examiner presses 0 and then the spacebar. Test
Question B: The item plays again and the audio recording continues: Now say the NEXT biggest animal.
Correct Response: If child says SHEEP, examiner presses 1 and then the spacebar. The audio recording
Incorrect Response: If child does not say SHEEP, examiner presses 0 and then the spacebar. The item
plays again and the audio recording says: Let’s try that again. The SHEEP is bigger than the RABBIT
(point) and the SHEEP is smaller than the ELEPHANT (point). We know that the RABBIT is the smallest
animal; say the next biggest animal. If child says SHEEP, examiner presses 1 and then the spacebar.
The audio recording says: Good job. The iPad automatically moves to the next question.
If child does not know next biggest animal after two trials, press 0 and then press spacebar. Test will be
discontinued.
Question C: The item plays again and the audio recording continues: Now say the biggest animal.
64
Correct Response: If child says ELEPHANT, examiner presses 1 and then the spacebar. The audio
Incorrect Response: If child does not say ELEPHANT, examiner presses 0 and then the spacebar. The
item plays again and the audio recording says: Let’s try that again. See, the ELEPHANT is bigger than
the RABBIT (point), and the ELEPHANT is bigger than the SHEEP (point). We know that the RABBIT is
the smallest animal, and the SHEEP is the next biggest animal; say the biggest animal. If child says
ELEPHANT, examiner presses 1 and then the spacebar. The audio recording says: Good job. The iPad
automatically moves to the next question.
If child does not know biggest animal after two trials, examiner presses 0 and then the spacebar. Test
Read the screen: Now we are going to do some more. This time, you’re only going to see one picture at
a time. You have to remember what you see and tell me the smaller and then the bigger animal. Let’s
start by looking together. Press Spacebar to continue.
Question A: The item plays. When the screen is blank, the audio recording says: Now, say the smaller
animal.
Correct Response: If child says DOG, examiner presses 1 and then the spacebar. The audio recording
Incorrect Response: If child does not say DOG, examiner presses 0 and then the spacebar. The item
plays again, and when the screen goes blank, the audio recording says: Let’s try that again. The DOG
is smaller than the HORSE. Now, say the smaller animal. : If child says DOG, examiner presses 1 and
then the spacebar. The audio recording says: Good job. The iPad automatically moves to the next
question.
If child does not know smaller animal after two trials, examiner presses 0 and then the spacebar. Test
Question B: The item plays again. When the screen is blank, the audio recording says: Now, say the
bigger animal.
Correct Response: If child says HORSE, examiner presses 1 and then the spacebar. The audio recording
Incorrect Response: If child does not say HORSE, examiner presses 0 and then the spacebar. The item
plays again. When the screen goes blank, the audio recording says: Let’s try that again. The DOG is
smaller than the HORSE. Now, say the bigger animal. If child says HORSE, examiner presses 1 and
question.
If child does not know bigger animal after two trials, examiner presses 0 and then the spacebar. Test will
be discontinued.
65
Read the screen: Now we are going to do some more. Are you ready? Press Spacebar to continue.
An audio recording with an accompanying animation says: This is a RABBIT (point to RABBIT); this is a
SHEEP (point); and this is an ELEPHANT (point).
Question A: When the screen is blank, the audio recording says: Say the smallest animal.
Correct Response: If child says RABBIT, examiner presses 1 and then the spacebar. The audio recording
Incorrect Response: If child does not say RABBIT, examiner presses 0 and then the spacebar. The item
plays again. When the screen goes blank, the audio recording says: Let’s try that again. The RABBIT
is smaller than the SHEEP (point), and the RABBIT is smaller than the ELEPHANT (point). The RABBIT
is the smallest animal. Now you say the smallest animal. If child says RABBIT, examiner presses 1 and
question.
If child does not know smallest animal after two trials, examiner presses 0 and then the spacebar. Test
Question B: The item plays again. When screen goes blank, the audio recording says: Now say the next
biggest animal.
Correct Response: If child says SHEEP examiner presses 1 and then the spacebar. The audio recording
Incorrect Response: If child does not say SHEEP, examiner presses 0 and then the spacebar. The item
plays again. When the screen goes blank, the audio recording says: Let’s try that again. The SHEEP is
bigger than the RABBIT (point) and the SHEEP is smaller than the ELEPHANT (point). We know that the
RABBIT is the smallest animal; say the next biggest animal. If child says SHEEP, examiner presses 1
and then the spacebar. The audio recording says: Good job. The iPad automatically moves to the next
question.
If child does not know next biggest animal after two trials, press 0 and then press spacebar. Test will be
discontinued.
Question C: The item plays again. When the screen goes blank, the audio recording says: Now, say the
biggest animal.
Correct Response: If child says ELEPHANT, examiner presses 1 and then the spacebar. The audio
Incorrect Response: If child does not say ELEPHANT, examiner presses 0 and then the spacebar. The
item plays again. When the screen goes blank, the audio recording says: Let’s try that again. The
ELEPHANT is bigger than the RABBIT (point), and the ELEPHANT is bigger than the SHEEP (point).
We know that the RABBIT is the smallest animal, and the SHEEP is the next biggest animal; say the
biggest animal. If child says ELEPHANT, examiner presses 1 and then the spacebar. The audio recording
If child does not know biggest animal after two trials, examiner presses 0 and then the spacebar. Test
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The 1-List practice items are summarized below:
P1 Presentation: Horse Dog (on screen)

Question Response Next step
Q-A1 Smaller? If Dog, press 1; If Horse, press 0 If 1, goes to Q-B1; If 0, goes to Q-A2
Q-A2 Smaller? If Dog, press 1; If Horse, press 0 If 1, goes to Q-B1; If 0, test
discontinued
Q-B1 Bigger? If Horse, press 1; If Dog, press 0 If 1, goes to P2; If 0, goes to Q-B2
Q-B2 Bigger? If Horse, press 1; If Dog, press 0 If 1, goes to P2; If 0, test discontinued
P2 Presentation: Elephant Rabbit Sheep (on screen)
Q-A1 Smallest? If Rabbit, press 1; If Elephant or If 1, goes to Q-B1; If 0, goes to Q-A2
Sheep,
press 0
Q-A2 Smallest? If Rabbit, press 1; If Elephant or If 1, goes to Q-B1; If 0, test
Sheep, press 0 discontinued
Q-B1 Next If Sheep, press 1; If Rabbit or If 1, goes to Q-C1; If 0, goes to Q-B2
Biggest? Elephant, press 0
Q-B2 Next If Sheep, press 1; If Rabbit or If 1, goes to Q-C1; If 0, test
Biggest? Elephant, press 0 discontinued
Q-C1 Biggest? If Elephant, press 1; If Rabbit or If 1, goes to P3; If 0, goes to Q-C2
Sheep, press 0
Q-C2 Biggest? If Elephant, press 1; If Rabbit or If 1, goes to P3; If 0, test discontinued
Sheep, press 0
P3 Presentation: Dog Horse (flashing)
Q-A1 Smaller? If Dog, press 1; If Horse, press 0 If 1, goes to Q-B1; If 0, goes to Q-A2
Q-A2 Smaller? If Dog, press 1; If Horse, press 0 If 1, goes to Q-B1; If 0, test
discontinued
Q-B1 Bigger? If Horse, press 1; If Dog, press 0 If 1, goes to P4; If 0, goes to Q-B2
Q-B2 Bigger? If Horse, press 1; If Dog, press 0 If 1, goes to P4; If 0, test discontinued
P4 Presentation: Presentation: Elephant Rabbit Sheep (flashing)
Q-A1 Smallest? If Rabbit, press 1; If Elephant or If 1, goes to Q-B1; If 0, goes to Q-A2
Sheep, press 0
Q-A2 Smallest? If Rabbit, press 1; If Elephant or If 1, goes to Q-B1; If 0, test
Q-B1 Next If Sheep, press 1; If Rabbit or If 1, goes to Q-C1; If 0, goes to Q-B2
Biggest? Elephant, press 0
Q-B2 Next If Sheep, press 1; If Rabbit or If 1, goes to Q-C1; If 0, test
Biggest? Elephant, press 0 discontinued
Q-C1 Biggest? If Elephant, press 1; If Rabbit or If 1, goes to 1-list test items; If 0, goes
Sheep, press 0 to Q-C2
Q-C2 Biggest? If Elephant, press 1; If Rabbit or If 1, goes to 1-list test items; If 0, test
1-List Test Items:

Read the screen: Let’s look at some more pictures. Remember, after you see the pictures you will
see a blank screen. Once you see this blank screen, I want you to tell me what you just saw in
67
size order from smallest to biggest. It is important to pay attention to the size of the object on the
screen when putting things in size order from smallest to biggest. Are you ready?
Press the spacebar to continue and the presentation of the 1-List test items will begin.
After the examiner chooses 1 or 0, the question-- Are you ready? -- appears on the screen. Once
confirming that the child is ready and attending, the examiner presses the spacebar to move on to the
next item (list of objects).
Note: For the examiner, there is a code at the bottom right side of the iPad screen to
indicate which item is being administered. The examiner should use this code to look up
the correct response on the Examiner Answer Sheet, and then score the item using the
keyboard (1 or 0).
68
2-List Condition
REVIEW: The 2-List practice items have the same format. First, the examiner asks for the food
from smallest to largest and then for the animals from smallest to largest. If the answer
is correct, the examiner moves on to the next question. If the child answers incorrectly,
there is another opportunity to answer correctly. The practice items are detailed below.
Read the screen: We’re going to look at more pictures. This time, you will see both food and
animals in a set of pictures. I’d like you to tell me the food first, and then the animals, in size order
from smallest to biggest. It is important to pay attention to the size of the object on the screen
when putting things in size order from smallest to biggest. Let’s start by looking at some more
pictures together. Press Spacebar to continue.
An audio recording with an accompanying animation says: This is a BEAR and this is a BANANA.
Question A:
The audio recording continues: Which one is a food.
Correct Response: If child says BANANA, examiner presses 1 and then the spacebar. The audio
Incorrect Response: If child does not say BANANA, examiner presses 0 and then the spacebar.
The item plays again and the audio recording says: Let’s try that again. The BEAR is an
animal; the BANANA is a food. Now you say the food. If child answers BANANA, examiner
presses 1 and then the spacebar. The audio recording says: Good job. The iPad automatically
moves to the next question.
If child does not know food after two trials, examiner presses 0 and then the spacebar. Test will
be discontinued.
Question B:
The item plays again and the audio recording continues: Now, say the animal.
Correct Response: If child says BEAR, examiner presses 1 and then the spacebar. The audio
Incorrect Response: If child does not say BEAR, examiner presses 0 and then the spacebar.
The item plays again and the audio recording says: Let’s try that again. The BANANA is a
food; the BEAR is an animal. Say the animal. If child answers BEAR, examiner presses 1 and
then the spacebar. The audio recording says: Good job. The iPad automatically moves to the
next question.
If child does not know animal after two trials, examiner presses 0 and then the spacebar. Test

An audio recording with an accompanying animation says: This is a PINEAPPLE (point); this is a FROG
(point); and this is a TIGER (point).
Question A:
69
The audio recording continues: Now, say the food.
Correct Response: If child says PINEAPPLE, examiner presses 1 and then the spacebar. The
audio recording says: Good job. The iPad automatically moves to the next question.
Incorrect Response:
If child does not say PINEAPPLE, examiner presses 0 and then the spacebar. The item plays
again and the audio recording says: Let’s try that again. The FROG and TIGER are animals
and the PINEAPPLE is a food (point). Now, say the food. If child says PINEAPPLE, examiner
presses 1 and then the spacebar. The audio recording says: Good job. The iPad automatically
moves to the next question.
If child does not know the food after two trials, examiner presses 0 and then the spacebar. Test
Question B:
The item plays again and the audio recording continues: Say the smaller animal.
Correct Response: If child says FROG, examiner presses 1 and then the spacebar. The audio
Incorrect Response: If child does not say FROG, examiner presses 0 and then the spacebar.
The item plays again and the audio recording says: Let’s try that again. The FROG and TIGER
are animals, and the FROG is smaller than the TIGER (point). The FROG is the smaller
animal. Now, say the smaller animal. If child says FROG, examiner presses 1 and then the
spacebar. The audio recording says: Good job. The iPad automatically moves to the next
question
If child does not know smaller animal after two trials, examiner presses 0 and then the spacebar.
Test will be discontinued.
Question C:
The item plays again and the audio recording continues: Say the bigger animal.
Correct Response: If child says TIGER, examiner presses 1 and then the spacebar. The audio
Incorrect Response: If child does not say TIGER, examiner presses 0 and then the spacebar.
The item plays again and the audio recording says: Let’s try that again. The FROG and TIGER
are animals, and the TIGER is bigger than the FROG (point). The FROG is the smaller
animal, and the TIGER is the bigger animal. Now you say the bigger animal. If child says
TIGER, examiner presses 1 and then the spacebar. The audio recording says: Good job. The
iPad automatically moves to the next question.
If child does not know bigger animal after two trials, examiner presses 0 and then the spacebar.
Test will be discontinued.

Read the screen: Now we are going to do some more. This time, we’re only going to see one picture
at a time. You are going to have to remember what you saw AND tell me the food first, then
the animal. Let’s start by looking together. Press spacebar to continue.
Question A:
70
The item plays. When screen goes blank, the audio recording says: Say the food.
Correct Response: If child says BANANA, examiner presses 1 and then the spacebar. The audio
Incorrect Response:
If child does not say BANANA, examiner presses 0 and then the spacebar. The item plays again
and the audio recording says: Let’s try that again. You saw a BANANA and a BEAR;
the BANANA is a food and the BEAR is an animal. Now, you say the food. If child
says BANANA, examiner presses 1 and then the spacebar. The audio recording says:
Good job. The iPad automatically moves to the next question.
If child does not know food after two trials, examiner presses 0 and then the spacebar. Test will
be discontinued.
Question B:
The item plays again. When screen goes blank, the audio recording continues: Now, say the
animal.
Correct Response: If child says BEAR, examiner presses 1 and then the spacebar. The audio
Incorrect Response:
If child does not say BEAR, examiner presses 0 and then the spacebar. The item plays again
and the audio recording says: Let’s try that again. The BANANA is a food; the BEAR
is an animal. Now, you say the animal. If child answers BEAR, examiner presses 1 and
then the spacebar. The audio recording says: Good job. The iPad automatically moves
to the next question.
If child does not know animal after two trials, examiner presses 0 and then the spacebar. Test
Question C:
After the child correctly identifies the food and the animal separately, the item plays once again.
When the screen goes blank, the audio recording says: Now, say the food, then the animal.
Correct Response: If child says BANANA, BEAR, examiner presses 1 and then the spacebar.
The audio recording says: Good job. The iPad automatically moves to the next question.
Incorrect Response:
If child says BEAR, BANANA or some other incorrect pair of words, examiner presses 0 and then
the spacebar. The item plays again and the audio recording says: Let’s try that again.
The BEAR is an animal; the BANANA is a food. Now, say the food, then the animal.
If child says BANANA, BEAR, examiner presses 1 and then the spacebar. The audio
If child does not know the food, then the animal after two trials, examiner presses 0 and then the
spacebar. Test will be discontinued.
Read the screen: Now we are going to do some more. Are you ready? Press spacebar to continue.
71
Question A:
The item plays. When screen goes blank, the audio recording says: Say the food.
Correct Response: If child says PINEAPPLE, examiner presses 1 and then the spacebar. The
audio recording says: Good job. The iPad automatically moves to the next question.
Incorrect Response:
If child does not say PINEAPPLE, examiner presses 0 and then the spacebar. The item plays
again and the audio recording says: Let’s try that again. You saw a PINEAPPLE, a
FROG and a TIGER. The FROG and TIGER are animals and the PINEAPPLE is a
food. Now, say the food. If child says PINEAPPLE, examiner presses 1 and then the
question.
If child does not know the food after two trials, examiner presses 0 and then the spacebar. Test
Question B:
The item plays again. When screen goes blank, the audio recording continues: Say the smaller
animal.
Correct Response: If child says FROG, examiner presses 1 and then the spacebar. The audio
Incorrect Response: If child does not say FROG, examiner presses 0 and then the spacebar.
The item plays again and the audio recording says: Let’s try that again. The FROG and
TIGER are animals and the FROG is smaller than the TIGER. The FROG is the
smaller animal. Now, you say the smaller animal. If child says FROG, examiner
presses 1 and then the spacebar. The audio recording says: Good job. The iPad
automatically moves to the next question.
If child does not know the smaller animal after two trials, examiner presses 0 and then the
Question C:
The item plays again. When screen goes blank, the audio recording continues: Now, say the
bigger animal.
Correct Response: If child says TIGER, examiner presses 1 and then the spacebar. The audio
Incorrect Response: If child does not say TIGER, examiner presses 0 and then the spacebar.
The item plays again and the audio recording says: Let’s try that again. You saw a
PINEAPPLE, a FROG and a TIGER; the FROG and TIGER are animals and the TIGER
is bigger than the FROG. The TIGER is the bigger animal. Now, you say the bigger
animal. If child says TIGER, examiner presses 1 and then the spacebar. The audio
If child does not know the bigger animal after two trials, examiner presses 0 and then the
Question D:
72
After the child correctly identifies the food and the animal separately, the item plays once again.
When the screen goes blank, the audio recording says: Now, say the food first and then the
animals in size order.
Correct Response: If child says PINEAPPLE, FROG, TIGER, examiner presses 1 and then the
question.
Incorrect Response: If child gives the wrong order, examiner presses 0 and then the spacebar.
The item plays again and the audio recording says: Let’s try that again. You saw a
PINEAPPLE, a FROG and a TIGER; the FROG and TIGER are animals and the TIGER is
bigger than the FROG. Now, say the food in size order starting with the smallest food, and
then the animals in size order, from smallest to biggest. If child says PINEAPPLE, FROG,
TIGER, examiner presses 1 and then the spacebar. The audio recording says: Good job. The
iPad automatically moves to the next question.
If child does not know the food first, then the animals in size order after two trials, examiner
presses 0 and then the spacebar. Test will be discontinued.
73
The 2-List practice items are summarized below:
P1 Presentation: Bear Banana (on screen)

Q-A1 Food? If Banana, press 1; If Bear, If 1, goes to Q-B1; If 0, goes to
press 0 Q-A2
Q-A2 Food? If Banana, press 1; If Bear, If 1, goes to Q-B1; If 0, test
press 0 discontinued
Q-B1 Animal? If Bear, press 1; If Banana, If 1, goes to P2; If 0, goes to Q-
press 0 B2
Q-B2 Animal? If Bear, press 1; If Banana, If 1, goes to P2; If 0, test
P2 Presentation: Frog Pineapple Tiger (on screen)
Q-A1 Food? If Pineapple, press 1; If Frog or If 1, goes to Q-B1; If 0, goes to
Tiger, press 0 Q-A2
Q-A2 Food? If Pineapple, press 1; If Frog or If 1, goes to Q-B1; If 0, test
Tiger, press 0 discontinued
Q-B1 Smaller animal? If Frog, press 1; If Pineapple or If 1, goes to Q-C1; If 0, goes to
Tiger, press 0 Q-B2
Q-B2 Smaller animal? If Frog, press 1; If Pineapple or If 1, goes to Q-C1; If 0, test
Q-C1 Bigger animal? If Tiger, press 1; If Frog or If 1, goes to P3; If 0, goes to Q-
Pineapple, press 0 C2
Q-C2 Bigger animal? If Tiger, press 1; If Frog or If 1, goes to P3; If 0, test
Pineapple, press 0 discontinued
P3 Presentation: Bear Banana (flashing)
Q-A1 Food? If Banana, press 1; If Bear, If 1, goes to Q-B1; If 0, goes to
press 0 Q-A2
Q-A2 Food? If Banana, press 1; If Bear, If 1, goes to Q-B1; If 0, test
Q-B1 Animal? If Bear, press 1; If Banana, If 1, goes to P2; If 0, goes to Q-
press 0 B2
Q-B2 Animal? If Bear, press 1; If Banana, If 1, goes to P2; If 0, test
P4 Presentation: Frog Pineapple Tiger (flashing)
Q-A1 Food? If Pineapple, press 1; If Frog or If 1, goes to Q-B1; If 0, goes to
Tiger, press 0 Q-A2
Q-A2 Food? If Pineapple, press 1; If Frog or If 1, goes to Q-B1; If 0, test
Q-B1 Smaller animal? If Frog, press 1; If Pineapple or If 1, goes to Q-C1; If 0, goes to
Tiger, press 0 Q-B2
Q-B2 Smaller animal? If Frog, press 1; If Pineapple or If 1, goes to Q-C1;If 0, test
Q-C1 Bigger animal? If Tiger, press 1; If Frog or If 1, goes to P3:If 0, goes to Q-
Pineapple, press 0 C2
Q-C2 Bigger animal? If Tiger, press 1; If Frog or If 1, goes to P3; If 0, test
Pineapple, press 0 discontinued
Q-D1 Food, then animals in If correct order, press 1; If If 1, goes to 2-list test items; If 0,
size order incorrect order, press 0 goes to Q-D2
74
Q-D2 Food, then animals in If correct order, press 1; If If 1, goes to 2-list test items; If 0,
size order incorrect order, press 0 test discontinued
2-List Test Items

Read the screen: Let’s look at some more pictures. Remember, after you see the pictures, you will
see a blank screen. Once you see this blank screen, tell me the foods first in size order
from smallest to biggest, then the animals, in size order from smallest to biggest. Are you
ready?
As before, after the examiner chooses 1 or 0, the question-- Are you ready? -- appears on the screen.
Once confirming that the child is ready and attending, the examiner presses the spacebar to move on to
the next item (list of objects).
There is a code at the bottom right side of the iPad screen to indicate which item is being
administered. The examiner should use this code to look up the correct response on the NIH Toolbox
List Sorting Working Memory Test Examiner Answer Sheet, and then score the item using the keyboard
(1 or 0).
75
C.2.3.2 NIH Toolbox List Sorting Working Memory Test Instructions Age 7+
iPad and have the keyboard and the NIH Toolbox List Sorting Working Memory Test Examiner Answer
Sheet easily accessible for scoring participant responses.
The task is introduced with the Title Screen: NIH Toolbox LS 7+. To check the Bluetooth connection,
the examiner is asked at the bottom of the page to: Press Spacebar to Continue. Touching the
spacebar begins the test. If the spacebar does not work, try repairing the keyboard or changing the
batteries in the keyboard.
REVIEW: All the 1-List practice items have the same format. First, the examiner asks for the names
of the pictures in size order from smallest to largest. If the participant answers incorrectly, there are
two more opportunities to get a correct answer. The first comes after a verbal explanation and a
repeat of the question; the second comes after replaying the item on the screen, followed by a verbal
explanation and then repeating the question. If, after three opportunities, the participant continues
to answer incorrectly, the test will be discontinued and no more items will be presented. Both practice
items are detailed below.
1-List Condition
Read the screen: You are going to see some pictures one at a time on the screen. After
each set of pictures, you will see a blank screen. When you see the blank screen, I want
you to tell me the names of the pictures in size order from smallest to biggest. For
example, if I show you a motorcycle, a bus, and a car, you would say: motorcycle, car, bus.
From now on, you will hear most of the instructions from the iPad. Do you have any
questions?
Let’s practice. Press Spacebar to continue.

Trial 1: After the pictures are presented and the screen is blank, an audio recording says: Now say
the animals in size order.
Correct Response: If participant says DOG, HORSE, press 1 and then press spacebar. An audio
recording says: That’s right. When it appears on the screen, ask: Are you ready? When the
participant answers affirmatively, press the spacebar and 1-List Practice Item 2 will be presented.
Incorrect Response: If participant does not say DOG, HORSE, press 0 and then press spacebar.
An audio recording says: Let’s try that again.
Trial 2 (if Trial 1 was incorrect): An audio recording continues: You saw a DOG and a HORSE; the
DOG is smaller than the HORSE. Now say the animals in size order.
Incorrect Response: If participant does not say DOG, HORSE, press 0 and then press spacebar.
An audio recording says: Let’s try that one more time.
Trial 3 (if Trial 2 was incorrect): After the pictures are presented one more time and the screen is
blank, an audio recording says: You saw a DOG and a HORSE; the DOG is smaller than the
HORSE. Now say the smaller animal and then the bigger animal.
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If participant answers the question incorrectly after 3 trials, press 0 and then press spacebar. Test

Trial 1: After the pictures are presented and the screen is blank, an audio recording says: Now say
the animals in size order, starting with the smallest animal.
Correct Response: If participant says RABBIT, SHEEP, ELEPHANT, press 1 and then press
spacebar. An audio recording says: That’s right. When it appears on the screen, ask: Are you
ready? When the participant answers affirmatively, press the spacebar and the 1-List introduction
screen will be presented.
Incorrect Response: If participant does not say RABBIT, SHEEP, ELEPHANT, press 0 and then
press spacebar. An audio recording says: Let’s try that again.
Trial 2 (if Trial 1 was incorrect): An audio recording continues: You saw a RABBIT, SHEEP and
ELEPHANT; the RABBIT is smaller than the SHEEP and the SHEEP is smaller than the
ELEPHANT. The RABBIT is the smallest animal, the SHEEP is the next biggest animal, and
the ELEPHANT is the biggest animal. Now, say the animals in size order, starting with the
smallest animal.
ready? When the participant answers affirmatively, press the spacebar and the 1-List introduction
Incorrect Response: If participant does not say RABBIT, SHEEP, ELEPHANT, press 0 and then
press spacebar. An audio recording says: Let’s try that once more.
Trial 3 (if Trial 2 was incorrect): After the pictures are presented again and the screen is blank, an
audio recording says: You saw a RABBIT, SHEEP and ELEPHANT; the RABBIT is smaller than
the SHEEP and the SHEEP is smaller than the ELEPHANT. The RABBIT is the smallest animal,
the SHEEP is the next biggest animal, and the ELEPHANT is the biggest animal. Now, say
the animals in size order, starting with the smallest animal.
ready? When the participant answers affirmatively, press the spacebar and presentation of the 1-
List introduction screen will be presented.
If participant answers the question incorrectly, press 0 and then press spacebar. Test will be
discontinued.
The 1-list practice items are summarized in the table below:
P1 Presentation: Horse Dog (Flashing)

Q1 Smaller first, then Bigger If Dog Horse, press 1; If Horse If 1, goes to P2; If 0, goes to
Dog, press 0 Q2
Q2 Smaller first, then Bigger If Dog Horse, press 1; If Horse If 1, goes to P2; If 0, goes to
Dog, press 0 Q3
Q3 Smaller first, then Bigger If Dog Horse, press 1; If Horse If 1, goes to P2; If 0, test
Dog, press 0 discontinued
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P2 Presentation: Elephant Rabbit Sheep (flashing)
Q1 Animals in size order, If Rabbit, Sheep, Elephant, press If 1, goes to 1-list test items;
starting with the smallest 1; If any other order, press 0 If 0, goes to Q2
starting with the smallest 1; If any other order, press 0 If 0, goes to Q3
starting with the smallest 1; If any other order, press 0 If 0, test discontinued
1-List Test Items:

Say: Let’s look at some more pictures. Remember, after you see the pictures you will see a blank
screen. Once you see this blank screen, I want you to tell me what you just saw in size order from
smallest to biggest. It is important to pay attention to the size of the object on the screen when
putting things in size order from smallest to biggest. Are you ready?
As noted earlier, after the examiner chooses 1 or 0, the question: Are you ready? appears on the screen.
Once confirming that the participant is ready and attending, the examiner presses the spacebar to move
on to the next item (list of objects).
For the examiner, there is a code at the bottom right side of the iPad screen to indicate which item is
being administered. The examiner should use this code to look up the correct response on the NIH
Toolbox List Sorting Working Memory Test Examiner Answer Sheet, and then score the item using the
keyboard (1 or 0).
78
2-List Condition
REVIEW: The 2-List practice items have the same format. First, the examiner asks for
the food from smallest to largest and then for the animals from smallest to largest. If the
answer is correct, the examiner moves on to the next question. If the participant answers
incorrectly, there are two more opportunities to get a correct answer. The first opportunity
comes after a verbal explanation and a repeat of the question; the second comes after
replaying the item on the screen, followed by a verbal explanation and then a repeat of
the question. If after a total of three opportunities, the participant continues to answer
incorrectly, the test will be discontinued and no more items will be presented. The
practice items are detailed below.
Say: We’re going to look at more pictures. This time, you will see both food and animals in a set
of pictures. I’d like you to tell me the food first, and then the animals, in size order from smallest
to biggest. It is important to pay attention to the size of the object on the screen when putting
things in size order from smallest to biggest. Let’s start by looking at some more pictures
together. Press Spacebar to continue.
After each answer, the examiner should indicate whether it was correct (1) or incorrect (0) on the
keyboard. Then the question Are you ready? appears on the screen. When the participant answers
affirmatively, the examiner should press the spacebar to continue.
Trial 1: After the pictures are presented and the screen is blank, an audio recording says: Say the
food, then the animal.
Correct Response: If participant says BANANA, BEAR, press 1 and then press spacebar. An audio
Incorrect Response: If participant does not say BANANA, BEAR, press 0 and then press spacebar.
An audio recording says: Let’s try that again.
Trial 2 (if Trial 1 was incorrect): An audio recording continues: The BEAR is an animal; the
BANANA is a food. Now say the food first and then the animal.
Correct Response: If participant says BANANA, BEAR, press 1 and then press spacebar. An audio
Incorrect Response: If participant does not say BANANA, BEAR, press 0 and then press spacebar.
An audio recording says: Let’s try that once more.
Trial 3 (if Trial 2 was incorrect): After the pictures are presented and the screen is blank, an audio
recording says: The BEAR is an animal; the BANANA is a food. Now say the food first and then
the animal. If participant says BANANA, BEAR, press 1 and then press spacebar. An audio
discontinued.
79
Trial 1: After the pictures are presented and the screen is blank, an audio recording says: Say the
food in size order from smallest to biggest and then say the animals in size order from
smallest to biggest.
Correct Response: If participant says PINEAPPLE, FROG, TIGER, press 1 and then press
ready? When the participant answers affirmatively, press the spacebar and the 2-list introduction
Incorrect Response: If participant does not say PINEAPPLE, FROG, TIGER, press 0 and then press
spacebar. An audio recording says: Let’s try that again.
Trial 2 (if Trial 1 was incorrect): An audio recording continues: You saw a frog, a pineapple, and a
tiger. The pineapple is a food; the frog is the smallest animal, and the tiger is the biggest
animal. Now, say the food in size order starting with the smallest food, and then the animals
in size order, from smallest to biggest.
ready? When the participant answers affirmatively, press the spacebar and the 2-list introduction
Incorrect Response: If participant does not say PINEAPPLE, FROG, TIGER, press 0 and an audio
recording says: Let’s try that one more time.
Trial 3 (if Trial 2 was incorrect): After the pictures are presented and the screen is blank, an audio
recording says: You saw a frog, a pineapple, and a tiger. The pineapple is a food; the frog is
the smallest animal, and the tiger is the biggest animal. Now, say the food in size order
starting with the smallest food, and then the animals in size order, from smallest to biggest.
ready? When the participant answers affirmatively, press the spacebar and presentation of the 2-
list introduction screen will be presented.
discontinued.
80
The 2-list practice items are summarized in the table below:
P1 Presentation: Bear Banana (Flashing)

Q1 Food first, then Animal If Banana Bear, press 1; If Bear If 1, goes to P2; If 0, goes to Q2
Banana, press 0
Q2 Food first, then Animal If Banana Bear, press 1; If Bear If 1, goes to P2; If 0, goes to Q3
Banana, press 0
Q3 Food first, then Animal If Banana Bear, press 1; If Bear If 1, goes to P2; If 0, test
Banana, press 0 discontinued
P2 Presentation: Frog Pineapple Tiger (flashing)
Q1 Food first, then Animals If Pineapple Frog Tiger, press 1; If If 1, goes to 2-list test items; If
in size order, any other order, press 0 0, goes to Q2
starting with the
smallest
in size order, any other order, press 0 0, goes to Q3
starting with the
smallest
in size order, any other order, press 0 0, test discontinued
starting with the
smallest
2-List Test Items

Read: Let’s look at some more pictures. Remember, after you see the pictures, you will see a
blank screen. Once you see this blank screen, tell me the foods first in size order from smallest
to biggest, then the animals, in size order from smallest to biggest. Are you ready? Press the
spacebar to continue and the presentation of the 2-List test items will begin.
As before, after the examiner chooses 1 or 0, the question: Are you ready? appears on the screen.
Once confirming that the participant is ready and attending, the examiner presses the spacebar to move
on to the next item (list of objects).
There is a code at the bottom right side of the iPad screen to indicate which item is being
administered. The examiner should use this code to look up the correct response on the NIH Toolbox
List Sorting Working Memory Test Examiner Answer Sheet, and then score the item using the keyboard
(1 or 0).
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C.2.4 NIH Toolbox Dimensional Change Card Sort Test (DCCS)
The NIH Toolbox Dimensional Change Card Sort Test is a measure of cognitive flexibility and attention.
Two target pictures are presented that vary along two dimensions (e.g., shape and color). Participants
are asked to match a series of bivalent test pictures (e.g., yellow balls and blue trucks) to the target
pictures, first according to one dimension (e.g., color) and then, after a number of trials, according to
the other dimension (e.g., shape).
The relevant dimension for sorting is indicated by a cue word (e.g., “shape” or “color”) that appears on
the screen for all participants and that, for young children ages 3-11, is also spoken by a prerecorded
audio file.
1. iPad
2. Home base
Practice items use white and brown colors and a Rabbit and Sailboat as shapes. Test items use blue and
yellow colors and a Ball and Truck as shapes.
All instructions are on the iPad screen: The examiner reads them to and/or with the participant
and points out the relevant aspects of the stimuli on the screen. The next screen appears when
either the examiner or participant makes a choice.
There are two versions of this measure for ages 3-7. The first is the standard NIH Toolbox DCCS test
for ages 3-7. The second is an experimental version (with “developmental extension,” or DEXT) that
was designed to extend the range of assessment downward, for those participants who have difficulty
understanding the standard task. Both versions yield a score for the standard measure, and the DEXT
version provides simple raw scores and percentages for the experimental items.
Standard administration:
Practice items
Participants of all ages are given four practice trials with each dimension – color and shape. If the
participant responds incorrectly, an audio recording prompts him/her to choose the correct image.
Similarly, a separate audio file plays each time the participant gets a practice item correct.
Rules:
• Participants must get at least three out of four practice trials correct to advance to the practice
trials for the next dimension and then to the test trials.
• If a participant of any age gets fewer than three out of four practice trials correct, he/she will
complete up to two more sets of four practice trials, with the same cutoff to advance to the test
trials.
• If a participant of any age does not meet the cutoff, the task will automatically discontinue.
If the participant does not respond after five seconds, the examiner should prompt him/her, saying:
Choose one of the pictures.
Test Trials
The examiner should not prompt the participant to respond during the test trials. If the participant
does not respond after ten seconds, the program will automatically advance to the next test trial.
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Ages 3-7
During the test trials, participants 3-7 years of age first complete a set of five trials to sort according
to color. If these young participants succeed in four of the five test trials, the program advances to
a set of five trials to sort according to shape.
If the young participants do not get four out of five test trials correct on either color or shape, the
test ends.
If participants ages 3-7 meet the criterion on the second set of test trials (i.e., post-switch), they will
complete the mixed block, consisting of 30 shape/color trials.
Because the mixed trials are scored for reaction time, these young participants need to be trained
in the use of Home Base, where the participant places his/her index finger between trials. Training
for Home Base precedes the introduction of the mixed trials for 3-7-year-olds.
Age 8+
Participants age 8+ receive training for Home Base before learning about the test. The test trials
for participants 8+ years of age consist of a mixed block of 30 shape/color items.
Developmental Extension (DEXT ages 3-7)
In this version, participants are given five practice trials on each dimension – color and shape. If the
participant responds incorrectly, an audio recording provides feedback and highlights the correct image.
Similarly, a separate audio file plays each time the participant gets a practice item correct.
Participants must succeed in 4 out of 5 practice trials in this version to move on.
If they do succeed, the test administration continues in the same manner as the standard administration
described above.
If they do not succeed on the practice trials of one dimension, they are directed to the developmental
extension of this measure. In addition, participants will be directed to the developmental extension if
they do not achieve 4 out of 5 correct on either the 5 color trials (“pre-switch”) or the 5 shape trials
(“post-switch”). The logic underlying this developmental extension is detailed in the test instructions
(DCCS 3-7 DEXT).
NIH Toolbox Dimensional Change Card Sort Test Ages 3-7
NIH Toolbox Dimensional Change Card Sort Test Ages 3-7 with Developmental Extension (DEXT)
NIH Toolbox Dimensional Change Card Sort Test Ages 8-11
NIH Toolbox Dimensional Change Card Sort Test Ages 12+
83
C.2.4.1 NIH Toolbox Dimensional Change Card Sort Test Instructions Ages 3-7
iPad screen written content Examiner (E) Actions
Title Screen NIH Toolbox DCCS 3-7 E touches and holds
button to continue.
Practice Intro We’re going to play a matching game with colors E reads screen, then
and shapes. touches and holds
button to continue.
SHAPE Intro We’ll play the SHAPE game first. In the SHAPE E points to BOAT, then
game, choose the picture that’s the same SHAPE demonstrates use of
as the picture in the middle of the screen. If it’s a button.
BOAT, choose this picture.
If it’s a RABBIT, choose that picture. E demonstrates use of

button
Transition Now you try. E reads screen, then

touches and holds
Keep your eyes on the star in the middle of the button to continue.
screen.
Shape Practice set 1 4 items sorted by shape
More practice, if less Let’s practice that some more. In the SHAPE game, E reads screen, then
than 3 out of 4 choose the picture that’s the same SHAPE as the chooses BOAT.
correct on set 1 picture in the middle of the screen. If it’s a BOAT,
choose this picture.
If it’s a RABBIT, choose that picture. E reads screen, then

chooses RABBIT.

touches and holds
screen.
More practice, if less Let’s practice that some more. In the SHAPE game, E chooses BOAT.
than 3 out of 4 choose the picture that’s the same SHAPE as the
correct on set 2 picture in the middle of the screen. If it’s a BOAT,
If it’s a RABBIT, choose that picture. E chooses RABBIT.

touches and holds
screen.
COLOR intro We can also match by COLOR. In the COLOR E points to, then
game, choose the picture that’s the same COLOR chooses, BROWN
picture.
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as the picture in the middle of the screen. If it’s
BROWN, choose this picture.
If it’s WHITE, choose that picture. E points to, then

chooses, WHITE picture.

touches and holds
screen.
Color Practice set 1 4 items sorted by color
More practice, if less Let’s practice some more. In the COLOR game, E chooses WHITE
than 3 out of 4 choose the picture that’s the same COLOR as the picture.
correct on set 1 picture in the middle of the screen. If it’s WHITE,
If it’s BROWN, choose that picture. E chooses BROWN

picture.

touches and holds
screen.
More practice, if less Let’s practice some more. In the COLOR game, E chooses WHITE
than 3 out of 4 choose the picture that is the same COLOR as the picture.
correct on set 2 picture in the middle of the screen. If it’s WHITE,

picture.

touches and holds
screen.
COLOR and SHAPE Now, we’re going to play with some different shapes E reads screen, then
intro and colors. This time we’ll use BALLS and TRUCKS touches and holds
that are YELLOW and BLUE. button to continue.
85
Pre-switch intro Let’s start with the COLOR game. Remember the E chooses BLUE picture.
COLOR game? In the COLOR game, choose the
picture that’s the same COLOR as the picture in the
middle of the screen. If it’s a BLUE one, choose this
picture.
And if it’s a YELLOW one, choose that picture. E chooses YELLOW

picture.

touches and holds
screen.
Color items 5 items sorted by color (if child does not get 4 of 5
correct, test terminates)
Test ends, if less than 4 of 5 correct
Post-switch intro Now we’re going to play the SHAPE game. E chooses TRUCK.
Remember the SHAPE game? In the SHAPE game,
choose the picture that’s the same SHAPE as the
picture in the middle of the screen. If it’s a TRUCK,
And if it’s a BALL, choose that picture. E chooses BALL.

touches and holds
screen.
Shape items 5 items sorted by shape
Test ends, if less than 4 of 5 correct
Home Base before We can also play both games together. But first we E reads screen and
Mixed Items are going to learn about Home Base. This is your points to the home base;
Home Base. Put your finger on the Home Base and then touches and holds
wait for the next picture. button to continue.
In this new game put your finger back on Home

Base after each answer.
Transition to Mixed Now we are ready to play both games together. E chooses TRUCK.
Trials Remember, when you hear the word SHAPE,
When you hear the word COLOR, choose the E chooses BLUE picture.
picture.
And if it’s a YELLOW one, choose that picture. E chooses YELLOW

picture.
86
touches and holds
screen.
Remember: Put your finger back on Home Base
after you answer.
Test items 30 mixed items
87
C.2.4.2 NIH Toolbox Dimensional Change Card Sort Test Ages 3-7 with Developmental
Extension (DEXT)
This table outlines the item content read by and the actions to be performed by the examiner and the
child.
iPad screen written content Examiner (E) & Child (C)
Actions
Title Screen NIH Toolbox DCCS 3-7 (DEXT) E touches and holds button
to continue.
Practice Intro We’re going to play a matching game with colors and E reads screen, then
shapes. touches and holds button to
continue.
SHAPE Intro We’ll play the SHAPE game first. In the SHAPE E points to BOAT, then
game, choose the picture that’s the same SHAPE as demonstrates use of button.
the picture in the middle of the screen. If it’s a BOAT,
If it’s a RABBIT, choose that picture. E demonstrates use of
button.
Keep your eyes on the star in the middle of the touches and holds button to
screen. continue.
Shape Practice 5 items sorted by shape
If less than 4 out Moves to developmental extension (DEXT Phase 1)
of 5 correct
COLOR intro We can also match by COLOR. In the COLOR game, E points to, then chooses,
choose the picture that’s the same COLOR as the BROWN picture.
picture in the middle of the screen. If it’s BROWN,
If it’s WHITE, choose that picture. E points to, then chooses,
WHITE picture.
screen. continue.
Color Practice 5 items sorted by color
of 5 correct
COLOR and Now, we’re going to play with some different shapes E reads screen, then
SHAPE intro and colors. This time we’ll use BALLS and TRUCKS touches and holds button to
that are YELLOW and BLUE. continue.
Pre-switch intro Let’s start with the COLOR game. Remember the E chooses BLUE picture.
COLOR game? In the COLOR game, choose the
picture.
And if it’s a YELLOW one, choose that picture. E chooses YELLOW picture.
screen. continue.
Color items 5 items sorted by color
of 5 correct
Post-switch Now we’re going to play the SHAPE game. E chooses TRUCK.
intro Remember the SHAPE game? In the SHAPE game,
88
Actions
screen. continue.
Shape items 5 items sorted by shape
of 5 correct
Home Base We can also play both games together. But first we E reads screen and points to
before Mixed are going to learn about Home Base. This is your the home base; then touches
Items Home Base. Put your finger on Home Base and wait and holds button to continue.
for the next picture. In this new game, put your finger
back on Home Base after each answer.
Transition to Now we are ready to play both games together. E chooses TRUCK.
Mixed Trials Remember, when you hear the word SHAPE, choose
the picture that’s the same SHAPE as the picture in
the middle of the screen. If it’s a TRUCK, choose this
picture.
When you hear the word COLOR, choose the picture E chooses BLUE picture.
that’s the same COLOR as the picture in the middle
of the screen. If it’s a BLUE one, choose this picture.
And if it’s a YELLOW one, choose that picture. E chooses YELLOW picture.
screen. Try to answer as fast as you can. continue.
Remember: Put your finger back on Home Base after
you answer.
89
DCCS Developmental Extension (DEXT) Phase 1 (Elephant/Fish)
Actions
1A: Screen 1 – Now we are going to play a different game. Look E reads screen and points
Instructions what I have here! I have a fish! Look at these boxes out the relevant aspects.
down here. This box has an elephant in it, and this After 10 seconds, the Touch
box has a fish in it. I’m going to put the fish in the and Hold Here to Continue
fish box because that is where it belongs. button appears. E then
touches and holds the button
to continue.
1A: Screen 2 – See, here is a fish. It goes in the fish box. E reads screen and touches
Demonstration the fish box, which makes a
clicking sound. The Touch
and Hold Here to Continue
button appears; then E
to continue.
1A: Screen 3 – Now, it’s going to be your turn to play the fish game! E reads screen. C touches
Fish Rule check Can you show me where the fish go in the fish a box.
game?
1: Screens 4a & b 4a (If correct) Very good, that’s right. E reads screen. Touch and
– Feedback Hold Here to Continue
button appears. Then E
touches and holds button to
advance to next screen.
4b (If incorrect) Uh oh. Remember, in this game, all Touch and Hold Here to
fish go in the fish box. Continue button appears;
after E touches and holds
button, screen says: Can
you show me where the
fish go in the fish game?
E reads screen and C
touches a box, triggering
either 4a or 4b.
When Touch and Hold Here
to Continue button appears
again, E touches and holds
button to advance to next
screen.
1A: Screen 5 – OK, let’s play! E reads screen and then
Transition touches and holds button to
1A: Screen 6 – If it’s a fish, then it goes in the fish box. (Appears E reads screen and points to
Rule reminder 1 above the fish box.) fish box; then E touches and
holds button to advance to
next screen.
1A: Screen 7 – Here is a fish. Where does it go? E reads screen. C touches
Live Trial 1 a box.
1A: Screen 8 – Fish go here. (Appears above the fish box.) E reads screen and points to
Rule reminder 2 fish box; then E touches and
holds button to go to next
screen.
Live Trial 2 a box.
90
Actions
next screen.
Live Trial 3 a box.
1A: Screen 12 – Fish go here. (Appears above the fish box.) E reads screen and points to
Rule reminder 4 fish box; then E touches and
next screen.
Live Trial 4 a box.
next screen.
Live Trial 5 a box.
If less than 4 of 5 correct, the test is discontinued.
If 4 or more correct, the test continues to Phase 1B.
1B: Screen 1 – Now we’re going to play a different game. Look E reads screen and points
Instructions what I have here! I have an elephant! I’m going to out the relevant aspects.
put the elephant in the elephant box because that’s After 8 seconds, the Touch
where it belongs. and Hold Here to Continue
button appears. Then E
to continue.
1B: Screen 2 – Now, it’s going to be your turn to put the elephant in E reads screen; after 2
Instructions the elephant box. seconds, Touch and Hold
Here to continue button
appears. Then E touches
and holds the button to
continue
OK, let’s play. E reads screen and then
1B: Screen 3 – If it’s an elephant, then it goes in the elephant box. E reads screen and points to
Rule reminder 1 (Appears above the elephant box.) elephant box; then E
1B: Screen 4 – Here is an elephant. Where does it go? E reads screen. C touches
Live trial 1 a box.
1B: Screen 5 – Elephants go here. (Appears above the elephant E reads screen, points to
Rule reminder 2 box.) elephant box and then E
continue.
Live trial 2 a box.
91
Actions
Live trial 3 a box.
1B: Screen 9 – Elephants go here. (Appears above the elephant E reads screen and points to
Rule reminder 4 box.) elephant box; then E
Live Trial 4 a box.
Live Trial 5 a box.
If less than 4 of 5 correct, the test is discontinued.
If 4 or more correct, the test continues to DEXT Phase 2.
92
DCCS Developmental Extension (DEXT)
Phase 2 (Big Kitty/Little Kitty)
Actions
2A: Screen 1 – Now, we’re going to play a different game. Here I have E reads screen and points
Instruction a little kitty and a big kitty. Look at these boxes down out the relevant aspects.
here. This one has a little kitty in it, and this one has a After 10 seconds, Touch and
big kitty in it. I’m going to put the little kitties in the little Hold Here to Continue button
kitty box. And I’m going to put the big kitties in the big appears. Then E touches
kitty box. and holds button to continue.
2A: Screen 2 – Here is a big kitty. It goes in the big kitty box. E reads screen and touches
Demonstration the big kitty box, which
makes a clicking sound.
Touch and Hold Here to
Continue button appears;
then E touches and holds
button to continue.
2A: Screen 3 – Here is a little kitty. It goes in the little kitty box. E reads screen and touches
Demonstration the little kitty box, which
makes a clicking sound.
Continue button appears;
then E touches and holds
button to continue.
2A: Screen 4 – Now, it’s going to be your turn. Put the little kitties in E reads screen, then touches
Instruction the little kitty box and the big kitties in the big kitty box. and holds the button to
continue.
2A: Screen 5 – Can you show me where the little kitties go? E reads screen. C touches a
Rule check box.
2A: Screens 6a & 6a (If correct) Very good, that’s right. E reads screen. Touch and
6b – Feedback Hold Here to Continue button
and holds button to continue.
6b (If incorrect) Uh oh. Remember, in this game, the big Touch and Hold Here to
kitties go in the big kitty box, and the little kitties go in Continue button appears;
the little kitty box. after E touches and holds
you show me where the
little kitties go? E reads
screen and C touches a box,
triggering either 6a or 6b.
Continue button appears
button to continue.
2A: Screen 7 – Can you show me where the big kitties go? E reads screen. C touches a
Rule check box.
8b – Feedback Hold Here to Continue button
appears. E touches and
holds button to continue to
next screen.
93
Actions
8b (If incorrect) Uh oh. Remember, in this game, the big Touch and Hold Here to
kitties go in the big kitty box, and the little kitties go in Continue button appears;
the little kitty box. after E touches and holds
you show me where the big
kitties go? E reads screen
and C touches a box,
triggering either 8a or 8b.
When Touch and Hold Here
to Continue button appears
button to continue.
2A: Screen 9 – OK, let’s put all the kitties in their boxes. E reads screen. Touch and
Transition Hold Here to Continue button
appears, then E touches and
2A: Screen 10 – If it’s a little kitty, then it goes in the little kitty box. If it’s E reads screen. After 5,
Rule reminder 1 a big kitty, then it goes in the big kitty box. (Text seconds, Touch and Hold
appears above relevant boxes.) Here to Continue button
and holds button to move to
next screen.
2A: Screen 11 – Here is a little kitty. Where does it go? E reads screen. C touches a
Live Trial 1 box.
2A: Screen 12 – Little kitties go here. Big kitties go here. (Text appears E reads screen. After 3
Rule reminder 2 above relevant boxes.) seconds, Touch and Hold
Here to Continue button
and holds button to advance
to next screen.
2A: Screen 13 – Here is a big kitty. Where does it go? E reads screen. C touches a
Live Trial 2 box.
2A: Screen 14 – If it’s a little kitty, then it goes in the little kitty box. If it’s E reads screen. After 5
and holds button to continue.
2A: Screen 15 – Here is a little kitty. Where does it go? E reads screen. C touches a
Live Trial 3 box.
2A: Screen 16 – Little kitties go here. Big kitties go here. (Text appears E reads screen. After 3
Rule reminder 4 above relevant boxes.) seconds, Touch and Hold
Live trial 4 box.
2A: Screen 18 – If it’s a little kitty, then it goes in the little kitty box. If it’s E reads screen. After 5
94
Actions
Live Trial 5 box.
If less than 4 of 5 correct, DEXT Phase 2 is discontinued (If DEXT started at Phase 2, Phase 1A items are
presented; depending on performance on Phase 1A items, Phase 1B items may be presented as well. Then
the test is discontinued).
If 4 or more correct, test continues to Phase 2B.
2B: Screen 1 – OK, now let’s play a silly game. Let’s put all the big E reads screen. After 7
Instructions kitties in the little kitty box and put all the little kitties in seconds, Touch and Hold
the big kitty box. This is a silly game. Here to Continue button
2B: Screen 2 – Let’s try this silly game! E reads screen. After 1
Instructions second, Touch and Hold
to next screen.
2B: Screen 3 – If it’s a little kitty, then it goes in the big kitty box. If it’s a E read screens. After 5
Rule reminder 1 big kitty, then it goes in the little kitty box (Text appears seconds, Touch and Hold
above reversed boxes.) Here to Continue button
2B: Screen 4 – Here is a little kitty. Where does it go? E reads screen. C touches a
Live trial 1 box.
2B: Screen 5 – Little kitties go here. Big kitties go here. (Text appears E reads screen. After 3
Rule reminder 2 above reversed boxes.) seconds, Touch and Hold
2B: Screen 6 – Here is a big kitty. Where does it go? E reads screen. C touches a
Live trial 2 box.
2B: Screen 7 – If it’s a little kitty, then it goes in the big kitty box. If it’s a E reads screen. After 5
Rule reminder 3 big kitty, then it goes in the little kitty box (Text appears seconds, Touch and Hold
next screen.
Live trial 3 box.
2B: Screen 9 – Little kitties go here. Big kitties go here. (Text appears E reads screen. After 3
Rule reminder 4 above reversed boxes.) seconds, Touch and Hold
to next screen.
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Actions
Live Trial 4 box.
2B: Screen 11 – If it’s a little kitty, then it goes in the big kitty box. If it’s a
E reads screen. After 5
Rule reminder 5 big kitty, then it goes in the little kitty box (Text appearsseconds, Touch and Hold
to next screen.
2B: Screen 12 – Here is a big kitty. Where does it go? E reads screen. C touches a
Live Trial 5 box.
If less than 4 of 5 correct, DEXT Phase 2 is discontinued (If DEXT started at Phase 2, Phase 1A items are
presented; depending on performance on Phase 1A items, Phase 1B items may be presented as well. Then
the test is discontinued). No Phase is administered more than once.
If 4 or more correct, the test continues to DEXT Phase 3.
96
DCCS Developmental Extension (DEXT) Phase 3 (Separated shape and color)

Actions
3A: Screen 1 – Now we’re going to play another game. Here is a E reads screen and points out
Instructions flower and here is a heart. This is the shape game. In the relevant aspects. After 10
the shape game, all the flowers go in the flower box, seconds, Touch and Hold Here
And all the hearts go in the heart box. to Continue button appears. E
continue.
3A: Screen 2 – See, here is a heart. It goes in the heart box. E reads screen and touches the
Instruction heart box, which makes a
clicking sound. Touch and Hold
appears; E touches and holds
the button to continue.
3A: Screen 3 – And here is a flower. It goes in the flower box. E reads screen and touches the
Instruction flower box, which makes a
clicking sound. Touch and Hold
appears; E touches and holds
the button to continue
3A: Screen 4 – Can you show me where the hearts go in the shape E reads screen. C touches a
Rule check game? box.
b – Feedback Hold Here to Continue button
appears. E touches and holds
screen.
5b (If incorrect) Uh oh. Remember, in the shape game, Touch and Hold Here to
hearts go in the heart box and flowers go in the flower Continue button appears; after
box. E touches and holds button,
screen says: Can you show
me where the hearts go? E
reads screen and C touches a
box, triggering either 5a or b.
When Touch and Hold Here to
Continue button appears again,
E touches and holds button to
3A: Screen 6 – Can you show me where the flowers go in the shape E reads screen. C touches a
Rule check game? box.
b – Feedback Hold Here to Continue button
appears. E touches and holds
screen.
5b (If incorrect) Uh oh. Remember, in the shape game, Touch and Hold Here to
hearts go in the heart box and flowers go in the flower Continue button appears; after
box. E touches and holds button,
screen says: Can you show
me where the flowers go? E
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Actions
reads screen and C touches a
box, triggering either 5a or b.
Continue button appears again,
E touches and holds button to
3A: Screens 8 – Now let’s do more like that! E reads screen. When Touch
Transition and Hold Here to Continue
button appears, E touches and
3A: Screen 9 – If it’s a flower, then it goes in the flower box. If it’s a E reads screen. After 5,
Rule reminder 1 heart, then it goes in the heart box. (Text appears seconds, Touch and Hold Here
above relevant boxes.) to Continue button appears.
Then E touches and holds
screen.
3A: Screen 10 – Here is a flower. Where does it go? E reads screen. C touches a
Live Trial 1 box.
3A: Screen 11 – Flowers go here. Hearts go here. (Text appears above E reads screen. After 3
Rule reminder 2 relevant boxes.) seconds, Touch and Hold Here
to Continue button appears. E
continue.
3A: Screen 12 – Here is a heart. Where does it go? E reads screen. C touches a
Live Trial 2 box.
3A: Screen 13 – If it’s a flower, then it goes in the flower box. If it’s a E reads screen. After 5,
above relevant boxes.) to Continue button appears. E
continue.
Live Trial 3 box.
3A: Screen 15 – Flowers go here. Hearts go here. (Text appears above E reads screen. After 3
Rule reminder 4 relevant boxes.) seconds, Touch and Hold Here
to Continue button appears. E
continue.
Live trial 4 box.
3A: Screen 17 – If it’s a flower, then it goes in the flower box. If it’s a E reads screen. After 5
above relevant boxes.) to Continue button appears. E
continue.
3A: Screen 18 – Here is a heart. Where does it go? E reads screen. C touches a
Live Trial 5 box.
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Actions
If less than 4 of 5 correct, DEXT Phase 3 is discontinued (If DEXT started at Phase 3, DEXT Phase 2A items
are presented and depending on performance on Phase 2A items, DEXT 2B OR DEXT 1A is presented. When
either or both (depending on performance) Phase 2A and 2B are administered, the test ends. When either or
both (depending one performance) Phase 1A and 1B items are administered, the test ends).
No Phase is administered more than once. If 4 or more correct on DEXT Phase 3A, the test continues to
Phase 3B.
3B: Screen 1 – Now we’re going to play a new game. We’re not going E reads screen. After 10
Instructions to play the shape game anymore. We’re going to play seconds, Touch and Hold Here
the color game. In the color game, all the pink ones go to Continue button appears. E
in the pink box. All the yellow ones go in the yellow touches and holds button to
box. advance to next screen.
3B: Screen 2 – Let’s try this game! E reads screen. After 1 second,
Instructions Touch and Hold Here to
Continue button appears. E
continue.
3B: Screen 3 – If it’s a pink one, then it goes in the pink box. If it’s a E reads screen. After 5
Rule reminder 1 yellow one, then it goes in the yellow box. (Text seconds, Touch and Hold Here
appears above relevant boxes.) to Continue button appears. E
continue.
3B: Screen 4 – Here’s a yellow one. Where does it go? E reads screen. C touches a
Live trial 1 box.
continue.
3B: Screen 6 – Here‘s a pink one. Where does it go? E reads screen. C touches a
Live trial 2 box.
continue.
3B: Screen 8 – Here’s a pink one. Where does it go? E reads screen. C touches a
Live trial 3 box.
continue.
Live Trial 4 box.
continue.
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Actions
Live Trial 5 box.
If less than 4 of 5 correct, DEXT Phase 3 is discontinued (If DEXT started at Phase 3, DEXT Phase 2A items
are presented; depending on performance on Phase 2A items, Phase 2B or Phase 1A is presented. When
either or both (depending on performance) Phase 2A and 2B are administered, the test ends; or, when either or
both (depending on performance) Phase 1A and 1B items are administered, the test ends).
No Phase is administered more than once. If 4 or more correct, test continues to DEXT Phase 4.
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Developmental Extension (DEXT) Phase 4 (Integrated color and shape) DCCS
iPad screen written content Examiner (E) & Child (C) Actions
4A: Screen 1 – Now we’re going to play the color E reads screen and points out the
Instructions game with different pictures. In this relevant aspects. After 8 seconds,
color game, all the red ones go in the Touch and Hold Here to Continue
red box. And all the blue ones go in button appears. E touches and holds
the blue box. the button to continue.
4A: Screen 2 – Here is a red one. It goes in the red E reads screen and touches the red
Demonstration box. box, which makes a clicking sound.
Touch and Hold Here to Continue
button appears; E touches and holds
the button to continue.
4A: Screen 3 – Here is a blue one. It goes in the blue E reads screen and touches the blue
Demonstration box. box, which makes a clicking sound.
Touch and Hold Here to Continue
button appears; E touches and holds
the button to continue
4A: Screen 4 – Can you show me where the blue E reads screen. C touches a box.
Rule check ones go in the color game?
4A: Screens 5a & b – 5a (If correct) Very good, that’s right. E reads screen. Touch and Hold Here
Feedback to Continue button appears. E touches
and holds button to advance to next
screen.
5b (If incorrect) Uh oh. Remember, in Touch and Hold Here to Continue

the color game, if it’s a blue one, then button appears; after E touches and
put it in the blue box, but if it’s a red holds button, screen says: Can you
one, put it in the red box. show me where the blue ones go? E
reads screen and C touches a box,
triggering either 5a or b.
Continue button appears again, E
touches and holds button to advance to
next screen.
4A: Screen 6 – Can you show me where the blue E reads screen. C touches a box.
Rule check ones go in the color game?
4A: Screens 7a & b – 5a (If correct) Very good, that’s right. E reads screen. Touch and Hold Here
Feedback to Continue button appears. E touches
and holds button to advance to next
screen.
5b (If incorrect) Uh oh. Remember, in Touch and Hold Here to Continue
the color game, if it’s a blue one, then button appears; after E touches and
put it in the blue box, but if it’s a red holds button, screen says: Can you
one, put it in the red box. show me where the red ones go? E
reads screen and C touches a box,
triggering either 5a or b.
Continue button appears again, E
touches and holds button to advance to
next screen.
4A: Screens 8 – Now let’s do some more like that! E reads screen. When Touch and Hold
Transition Here to Continue button appears, E
touches and holds button to continue.
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4A: Screen 9 – If it’s a red one, then it goes in the red E reads screen. After 5, seconds,
Rule reminder 1 box. If it’s a blue one, then it goes in Touch and Hold Here to Continue
the blue box. (Text appears above button appears. E touches and holds
relevant boxes.) button to continue.
4A: Screen 10 – Here is a red one. Where does it go? E reads screen. C touches a box.
Live Trial 1
4A: Screen 11 – Red ones go here. Blue ones go here. E reads screen. After 3 seconds, Touch
Rule reminder 2 (Text appears above relevant boxes.) and Hold Here to Continue button
appears. E touches and holds button to
continue.
4A: Screen 12 – Here is a blue one. Where does it go? E reads screen. C touches a box.
Live Trial 2
4A: Screen 13 – If it’s a red one, then it goes in the red E reads screen. After 5 seconds,
Rule reminder 3 box. If it’s a blue one, then it goes in Touch and Hold Here to Continue
the blue box. (Text appears above button appears. E touches and holds
4A: Screen 14 – Here is a blue one. Where does it go? E reads screen. C touches a box.
Live Trial 3
4A: Screen 15 – Red ones go here. Blue ones go here. E reads screen. After 3 seconds, Touch
Rule reminder 4 (text above relevant boxes) and Hold Here to Continue button
continue.
Live trial 4
4A: Screen 17 – If it’s a red one, then it goes in the red E reads screen. After 5 seconds, Touch
Rule reminder 5 box. If it’s a blue one, then it goes in and Hold Here to Continue button
the blue box. (Text appears above appears. E touches and holds button to
relevant boxes.) continue.
Live Trial 5
If less than 4 of 5 correct, the test is discontinued. If 4 or more correct, the test continues to Phase 4B.
4B: Screen 1 – Now we’re going to play a different E reads screen. After 10 seconds,
Instructions game. We’re not going to play the Touch and Hold Here to Continue
color game anymore. We’re going to button appears. E touches and holds
play the shape game. In the shape button to advance to next screen.
game, all the stars go in the star box.
All the airplanes go in the airplane
box.
4B: Screen 2 – Let’s try this game! E reads screen. After 1 second, Touch
Transition and Hold Here to Continue button
continue.
4B: Screen 3 – If it’s an airplane, then it goes in the E reads screen. After 5 seconds, Touch
Rule reminder 1 airplane box. If it’s a star, then it goes and Hold Here to Continue button
in the star box. (Text appears above appears. E touches and holds button to
4B: Screen 4 – Here is an airplane. Where does it E reads screen. C touches a box.
Live trial 1 go?
4B: Screen 5 – Airplanes go here. Stars go here E reads screen. After 3 seconds, Touch
Rule reminder 2 (Text appears above relevant boxes.) and Hold Here to Continue button
continue.
4B: Screen 6 – Here is a star. Where does it go? E reads screen. C touches a box.
Live trial 2
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4B: Screen 7 – If it’s an airplane, then it goes in the E reads screen After 5 seconds, Touch
Rule reminder 3 airplane box. If it’s a star, then it goes and Hold Here to Continue button
in the star box. (Text appears above appears. E touches and holds button to
4B: Screen 8 – Here is an airplane. Where does it go? E reads screen. C touches a box.
Live trial 3
4B: Screen 9 – Airplanes go here. Stars go here (text E reads screen. After 3 seconds, Touch
Rule reminder 4 above boxes) and Hold Here to Continue button
continue.
4B: Screen 10 – Here is an airplane. Where does it E reads screen. C touches a box.
Live Trial 4 go?
4B: Screen 11 – If it’s an airplane, then it goes in the E reads screen. After 5 seconds,
Rule reminder 5 airplane box. If it’s a star, then it goes Touch and Hold Here to Continue
in the star box. (Text appears above button appears. E touches and holds
4B: Screen 12 – Here is a star. Where does it go? E reads screen. C touches a box.
Live Trial 5
DEXT Phase 4 is complete. End of DCCS.
103
C.2.4.3 Dimensional Change Card Sort Test Instructions Ages 8-11
Title Screen NIH Toolbox DCCS 8-11 E touches and holds

button to continue
Home Base Intro We’re going to play a matching game with colors and shapes. Reads screen and
But first we are going to learn about Home Base. This is your points to Home Base;
Home Base. Put your finger on the Home Base and wait for then touches and holds
the next picture. button to continue.
SHAPE intro We’ll play the SHAPE game first. In the SHAPE game, E points to BOAT, then
choose the picture that’s the same SHAPE as the picture in demonstrates use of
the middle of the screen. If it’s a BOAT, choose this picture. button.
If it’s a RABBIT, choose that picture. E points to RABBIT,

then touches and holds
button to continue.

touches and holds
Put your finger back on Home Base after you answer.

Set 1
More practice, if Let’s practice that some more. In the SHAPE game, choose E chooses BOAT.
less than 3 out of the picture that’s the same SHAPE as the picture in the
4 correct on Set 1 middle of the screen. If it’s a BOAT, choose this picture.

touches and holds

Set 2
More practice, if Let’s practice that some more. In the SHAPE game, choose E chooses BOAT.
less than 3 out of the picture that’s the same SHAPE as the picture in the
4 correct on Set 2 middle of the screen. If it’s a BOAT, choose this picture.
104

touches and holds

Set 3
Test ends, if less than 3 out of 4 correct on Set 3
COLOR intro We can also match by COLOR. In the COLOR game, choose E points to, then
the picture that’s the same COLOR as the picture in the chooses, BROWN
middle of the screen. If it’s BROWN, choose this picture. picture.

chooses, WHITE
picture.

touches and holds
Color Practice Set 4 items sorted by color

1
More practice, if Let’s practice some more. In the COLOR game, choose the E chooses WHITE
less than 3 out of picture that’s the same COLOR as the picture in the middle of picture.
4 correct on Set 1 the screen. If it’s WHITE, choose this picture.

picture.

touches and holds

2
105
More practice, if Let’s practice some more. In the COLOR game, choose the E chooses WHITE
less than 3 out of picture that’s the same COLOR as the picture in the middle of picture.
4 correct on Set 2 the screen. If it’s WHITE, choose this picture.

picture.

touches and holds

3
Test ends, if less than 3 out of 4 correct on Set 3
Test item intro Now we’re going to play both games together. E reads screen, then
Remember, if you see and hear the word SHAPE, you touches and holds button to
choose the picture that’s the same SHAPE as the picture continue.
in the middle of the screen. If you see and hear the word
COLOR, you choose the picture that’s the same COLOR
as the picture in the middle of the screen.

answer.

Keep your eyes on the star. Answer as fast as you can continue.
C.2.4.4 Dimensional Change Card Sort Test Instructions Ages 12+

Title Screen NIH Toolbox DCCS 12+ E touches and holds
button to continue
Home Base We’re going to play a matching game with colors and shapes. But E reads screen and
Intro first we are going to learn about Home Base. This is your Home points to Home Base;
Base. Put your finger on the Home Base and wait for the next then touches and holds
picture. button to continue.
106
SHAPE intro We’ll play the SHAPE game first. In the SHAPE game, choose E points to BOAT, then
the picture that’s the same SHAPE as the picture in the middle of demonstrates use of
the screen. If it’s a BOAT, choose this picture. button.
If it’s a RABBIT, choose that picture. E points to RABBIT,
then touches and holds
button to continue.
Keep your eyes on the star. Answer as fast as you can without touches and holds
making mistakes. button to continue.
set 1
More practice, Let’s practice that some more. In the SHAPE game, choose the E chooses BOAT.
if less than 3 picture that’s the same SHAPE as the picture in the middle of the
out of 4 correct screen. If it’s a BOAT, choose this picture.
on set 1
set 2
More practice, Let’s practice that some more. In the SHAPE game, choose the E chooses BOAT.
if less than 3 picture that’s the same SHAPE as the picture in the middle of the
out of 4 correct screen. If it’s a BOAT, choose this picture.
on set 2
set 3
COLOR intro We can also match by COLOR. In the COLOR game, choose the E points to, then
picture that’s the same COLOR as the picture in the middle of the chooses, BROWN
screen. If it’s BROWN, choose this picture. picture.
chooses, WHITE
picture.
set 1
More practice, Let’s practice some more. In the COLOR game, choose the E chooses WHITE
if less than 3 picture that’s the same COLOR as the picture in the middle of the picture.
out of 4 correct screen. If it’s WHITE, choose this picture.
on set 1
picture.
set 2
107
More practice, Let’s practice some more. In the COLOR game, choose the E chooses WHITE
if less than 3 picture that’s the same COLOR as the picture in the middle of the picture.
out of 4 correct screen. If it’s WHITE, choose this picture.
on set 2
picture.
set 3
Test item intro Now we’re going to play both games together. Remember, if you E reads screen, then
see the word SHAPE, you choose the picture that is the same touches and holds
SHAPE as the picture in the middle of the screen. If you see the button to continue.
word COLOR, you choose the picture that is the same COLOR
as the picture in the middle of the screen.
answer.
If you make a mistake, just keep going.
108
C.2.5 NIH Toolbox Pattern Comparison Processing Speed Test
The NIH Toolbox Pattern Comparison Processing Speed Test is designed to measure processing
speed. The test itself takes less than 90 seconds and requires participants to discern whether two side-
by-side pictures are the same or not.
Younger children make this decision by choosing either a “smiley face” (corresponding to a “yes”
response) or a “frowny face” (corresponding to a “no” response). Older children and adults (Ages 7+)
make this decision with “yes” or “no” buttons on the screen
Equipment needed:
a. iPad
b. Small ball (optional)
Practice Items:
Young children are administered two demonstration items and five practice items; older children and
adults are administered six practice items.
All participants touch the buttons that matches their choice: “smiley face” or “yes” for same or look alike
or “frowny face” or “no” for not the same or do not look alike. The practice items are not timed. If a
participant (child or adult) continues to make an error after being corrected on two practice items, the
test will discontinue.
For both test and practice items, if there is no response in 10 seconds, the pre-recorded audio asks:
Are these the same?
During practice items only, an audio recording will follow each item presentation:
If the item is correct, an audio recording will say: That’s right.
If the item is incorrect, an audio recording will say why the item is incorrect. The item will appear a
second time and the participant will be asked to respond again.
If a participant (child or adult) continues to make an error after being corrected two times on two
different practice items, the test will discontinue.
Test items:
There are a maximum of 130 items or a maximum response time of 85 seconds.
Prompts:
Some participants need reminders to stay on task. The examiner may give prompts, although fewer are
better as this is a timed task. Each prompt should be succinct.
Examples are: look at the screen; are these the same, yes or no; remember to choose a button;
remember to choose as quickly as you can.
Handedness: If this was not entered during registration, the iPad app will not allow this test to be
administered. Instead, the examiner will need to ask a set of questions to ascertain handedness and to
enter it in the participant registration screen. Please refer to Appendix 2 for details.
109
Once handedness is entered in the participant registration screen, it will automatically update the
instructions on the test so that “RIGHT” or “LEFT” is displayed where appropriate
IMPORTANT REMINDER: Unlike some of the other tasks, if participants have difficulty touching the
screen, the examiner cannot answer for them, as this task measures processing speed and having the
examiner answer would compromise the accuracy of this measurement.
Participants may be given a small stress ball to keep in their non-dominant hand.
NIH Toolbox Pattern Comparison Processing Speed Test Instructions Ages 3-6
NIH Toolbox Pattern Comparison Processing Speed Test Instructions Ages 7+
110
C.2.5.1 Pattern Comparison Processing Speed Test Instructions Ages 3-6
The task is introduced with the Title Screen: NIH Toolbox PC 3-6. At the bottom of the screen is a
Read the screen: I would like you to use the pointer (index) finger of this (point to dominant right or
left as appropriate) hand to answer.
Let’s look at these two faces. One of them is a SMILEY face and the other is a FROWN face
(point to each).
Touch and hold button that says: Touch and hold here to continue.
Read the screen: Now I am going to show you some pictures. On each screen, there will be two
pictures. Sometimes the pictures look alike or the same, and sometimes the pictures do not
look alike and are NOT the same.
When the pictures look alike or the same, you should choose the SMILEY face. When they do
NOT look alike or the same, you should choose the FROWN face.
Touch and hold button that says: Touch and hold here to continue.
111
Ages 3-6 Practice Item 1:
Read the screen: Look at the boxes on the screen; in them are two pictures: this picture (point to
left box) and this picture (point to right box). These two pictures look alike or the same, so we’ll
choose the SMILEY face. Let’s choose the SMILEY face together.
Audio recording says: Great job! when the SMILEY face is touched. Next item will appear.
Read the screen: Look at these pictures here. This picture (point) and this picture (point) do NOT
look alike or the same. This picture (point) is purple but this picture (point) is orange. This means
the pictures are NOT alike, so we’ll choose the FROWN face. Let’s choose the FROWN face
together and then you will do some practice.
Audio recording says: Great job! when FROWN face is touched. Next item will appear.
Audio recording says: Are these the same? Remember, touch the SMILEY face if they look alike or
are the same and touch the FROWN face if they do not look alike and are NOT the same.
Pictures will stay on screen, until there is a response and audio recording will repeat: Are these the
same?
If correct (SMILEY face), the audio recording says: Great job! Next item will appear.
112
If incorrect (FROWN face), the audio recording says: The pictures look alike, the same. Both
pictures are flowers that are the same size and color, so choose the SMILEY face. SMILEY face
will flash; item will stay on screen.
If no response, the audio recording repeats: Are these the same?
If child chooses correctly, the audio recording will say: Great job! Next item will appear.
If child chooses incorrectly another time, iPad program moves to next practice item after repeating
explanation above.
Audio recording says: Are these the same? Pictures will stay on screen, until there is a response and
audio recording will repeat: Are these the same?
If correct (FROWN face), the audio recording says: Great job! Next item will appear.
If incorrect (SMILEY face), the audio recording says: These pictures do not look alike and are NOT
the same. One picture is a flower with a stem and one picture is only the top of a flower, with no
stem. Choose the FROWN face. FROWN face will flash; item will stay on screen.
explanation above.
If correct (SMILEY face), the audio recording says: Great job! Next item will appear.
If incorrect (FROWN face), the audio recording says: These pictures look alike, the same. Both are
pictures of a present or gift box, so choose the SMILEY face. SMILEY face will flash; item will stay
on screen.
113
explanation above.
If correct (FROWN face), the audio recording says: Great job! Next item will appear.
If incorrect (SMILEY face), the audio recording says: These pictures do not look alike and are NOT
the same. One flower is purple and the other flower is red; so choose the FROWN face. FROWN
face will flash; item will stay on screen.
explanation above.
If correct (SMILEY face), the audio recording says: Great job! Practice items are complete.
If incorrect (FROWN face), the audio recording says: These pictures look alike. Both are pictures of
red flowers, so choose the SMILEY face. SMILEY face will flash; item will stay on screen.
114
explanation above.
Test Items:
NOTE: If the child has not correctly chosen the SMILEY or FROWN face after two trials on
two practice items 3-7, testing will automatically be discontinued and iPad will
move on to the next test.
Test Items:
Read the screen: Now you’ll do some more. Remember, touch the SMILEY face if the pictures
look alike or are the same and touch the FROWN face if they do not look alike and are NOT the
same. Make a choice as quickly as you can. Are you ready?
When ready, touch and hold button that says: Touch and hold here to continue.
For both test and practice items, if participant does not respond within 10 seconds, audio recording
asks: Are these the same?
When either 130 items appear or 85 seconds of testing time has occurred, the test will
end (if a participant is working on an item when time is up, he/she will be permitted to
complete it).
115
C.2.5.2 Pattern Comparison Processing Speed Test Instructions Ages 7+
The task is introduced with the Title Screen: NIH Toolbox PC 7+. At the bottom of the screen is a
An audio recording says:
On each screen, you are going to see two pictures. Sometimes the two pictures are the same
and sometimes the two pictures are NOT the same. If the pictures look the same, touch the ‘Yes’
button. If they do NOT look the same, touch the NO button. If you make a mistake during the
practice, you will hear a message to try again. Use your ______ (dominant hand from handedness,
audio will say “right” or “left”) index finger to respond. Let's try some for practice.
When the audio recording is complete, Touch and hold here to continue appears on the screen.
Touch and hold that button to begin the administration.
Practice Items:
There are 6 practice items. The first practice item is introduced with an audio recording asking: Are
these the same? Remember, touch YES if they look alike or are the same and touch NO if they
do not look alike and are NOT the same.
For the other five practice items, an audio recording asks: Are these the same?
If the participant answers correctly, an audio recording says: That’s right! The next item will appear.
If the participant answers incorrectly, an audio recording explains why the answer is wrong. The
correct answer will flash; item will stay on screen. If participant chooses correctly, an audio recording
will say: That’s right! and the next item will appear.
If the participant chooses incorrectly another time, the program automatically moves to the next practice
item after repeating the explanation above.
Practice item Correct response Incorrect response

1 Yes: both yellow flowers No
2 No: a flower with stem & top of a flower Yes
3 No: one present & many presents Yes
4 Yes: both single presents No
5 No: purple flower & red flower Yes
6 Yes: both red flowers No
NOTE: If a participant makes an error a second time after being corrected on two different
practice items, the test will discontinue.
Test Items:
116
An audio recording introduces the test items: Now we’ll do some more. Remember, use your ______
(right/left; audio will say the dominant one) index finger to respond. Touch YES if the pictures look
the same and touch NO if they do NOT look the same. It is important that you choose as quickly
as you can.
When the audio file is complete, Touch and hold here to continue appears on the screen. Touch and
hold that button to continue with the test items.
For both test and practice items, if the participant does not respond within 10 seconds, the audio asks:
Are these the same?
When either 130 items appear or 85 seconds of testing time has occurred, the test will end (if a
participant is working on an item when time is up, he/she will be permitted to complete it).
117
C.2.6 NIH Toolbox Picture Sequence Memory Test
In this measure of episodic memory, sequences of pictured objects and activities are presented in a
particular order. The participants are asked to reproduce the sequence of pictures that is shown on the
screen.

II. iPad
There are three different sets (forms) of test items for this measure: forms A, B, and C. Each form has
different test items that yield equivalent scores and can be used in a repeated measures research
design to minimize practice effects. The forms are typically given in alphabetical order but may be given
in any order as indicated by the user.
There are also different practice sequences and test items for participants of different ages: 3-4, 5-6, 7
and 8+. For each age group, there is the option to use one of the three forms: A, B, or C.
Special Instructions:
For all participants, a demonstration sequence shows participants how to move the pictures on the
screen. After this, there are practice sequences that differ for participants of differing ages: 3-4, 5-6, 7
and 8+ years. In addition, the test sequences differ in length for participants of differing ages.
Participants respond by dragging pictures from the yellow box on the screen into the gray boxes on the
screen. They may verbalize the picture labels as they move the pictures. If, however, verbalizing the
picture labels seems to interfere with the participant’s performance, the examiner should say: “You
don’t need to say the words/labels.” If participants indicate that saying the labels helps them, the
examiner may reassure them that they may say the labels if they wish.
If participants look away from the screen while the pictures are being presented, the examiner should
remind them to: Watch the screen. Additionally, examiners should not allow participants to touch the
screen while the pictures are being presented. If participants try to touch the screen while pictures are
being presented or while the examiner is giving instructions, say: “Do not touch the screen until l tell
you that it is your turn.”
If necessary, remind participants to: Wait until I tell you it is your turn (to touch the screen).
If the participant has difficulty dragging the pictures across the screen during the demonstration
sequence, practice sequences, or the actual test sequences, he/she may point and the examiner
should move the pictures in the way the participant indicates. The examiner should ensure the
participant completely understands how the process will work and should say something like the
following to the participant: You point to the picture you want to move, then point to the grey box where
you want to move it. I’ll move it there for you.
NIH Toolbox Picture Sequence Memory Test Ages 3-4
118
NIH Toolbox Picture Sequence Memory Test Ages 5-6
NIH Toolbox Picture Sequence Memory Test Age 7
NIH Toolbox Picture Sequence Memory Test Ages 8+
119
C.2.6.1 Picture Sequence Memory Test Instructions Ages 3-4
If the child has difficulty dragging the pictures across the screen, during the demonstration sequence,
practice sequences, or the actual test sequences, he/she may point and the examiner will move the
pictures in the way the child indicates. The examiner should ensure the child completely understands
how the process will work and can say something like the following: You point to the picture you
want to move, then point to the gray box where you want to move it. I’ll move it there for you.
The test begins with a Title Screen: NIH Toolbox PSM 3-4 Form (A, B, or C). At the bottom of the
screen is a button Touch and Hold Here to Continue. Touch and hold that button to begin the test.
On the next screen, read the text: Now we are going to play a memory game, but first I am going to
teach you how to move the pictures on this screen. When finished reading, touch the button at the
bottom of the screen that says Touch and Hold Here to Continue.
The next screen begins the three-step demonstration sequence. If the steps are not followed, the
Touch and Hold Here to Continue button will not be active.
Step 1: Moving Pictures from the Yellow Box to the Gray Boxes
Read the text above the yellow box on the screen and demonstrate the actions described.
Say: Here you see some pictures in a yellow box. I want to show you how to move the pictures to
the gray boxes. You can move pictures from this yellow box to the gray boxes, like this. Touch
on the picture in the yellow box; then drag the picture you touched to the gray box where you
want to move it. Now you try with this picture.
After the child demonstrates understanding of this step, touch the button at the bottom of the screen
that says Touch and Hold Here to Continue.
Step 2: Moving Pictures from the Gray Boxes to the Yellow Box
Say: You can also move pictures from the gray boxes back to the yellow box, like this. Touch the
picture you want to move. Then drag that picture to the yellow box. Now you move the other
picture back to the yellow box.
Step 3: Moving Pictures between the Gray Boxes
Say: You can also move the pictures from one gray box to another, like this. First, you touch the
picture in one gray box. Then, drag that picture to the gray box where you want the picture to go.
Now you try it; move the picture from here to here.
Introduction to the Practice Items
120
Read the screen: Now, we’re going to play the game. You will see some pictures on the
screen. You should remember them and show them back to me in the same way you saw them
on the screen.
When finished reading, touch the button at the bottom of the screen that says Touch and Hold Here to
Continue.
The next screen begins the practice sequences. There are two practice sequences. If the child does not
succeed after two trials on first practice sequence of two pictures, the test is discontinued. The second
practice sequence has three pictures; if the child succeeds in four or fewer trials, the test sequence is
started. If the child does not succeed on the second practice sequence after four trials, the test is
discontinued.
Practice Sequence 1:
Say: Now, you will see how to Eat Ice Cream. When finished reading, touch and hold the button at
the bottom of the screen that says Touch and Hold here to Continue.
As the pictures are presented, an audio recording will say appropriate labels:
First, put a scoop on the cone.

Then, eat the ice cream.
After the pictures are presented and as the pictures are scrambled, an audio recording will say: That’s
how to Eat Ice Cream. Now, you move the pictures in the same way you saw them on the
screen.
When all pictures have been placed in gray boxes, a pop-up will appear on the screen, “Are you
finished?” Ask this of the child.
If child says YES, touch and hold the YES button. If the child says NO, touch any of the pictures and the
pop-up will disappear. If no picture is moved out of a gray box, the pop-up will continue to be on the
screen. The pop-up will close if a picture is moved back to the yellow box and will reappear each time
all pictures have been placed in gray boxes.
Logic:
1. If child gives correct response: Practice sequence 2, Have a Birthday Party, will be presented.
2. If child gives incorrect response: Eat Ice Cream will be presented again with an audio recording that
says: Let’s try that again
how to Eat Ice Cream. Now, you move the pictures in the same way you saw them on the
screen. The examiner may have to explain that the child made a mistake on the first trial.
If child fails both trials of Practice Sequence 1, test will discontinue.
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Say: That’s right. Now, you will see how to have a Birthday Party. When finished reading, touch
and hold the button at the bottom of the screen that says Touch and Hold Here to Continue.
First, bake the cake.

Next, frost it.
And last, put on the candles.
how to have a Birthday Party. Now, you move the pictures in the same way you saw them on the
screen.
Logic:
1. If child gives correct response, Test Item will be presented.
2. If child gives incorrect response, Have a Birthday Party will be presented again with an
audio recording saying, “Let’s try that again.” After the pictures are presented and as the
pictures are scrambled, an audio recording will say: That’s how to Have a Birthday Party.
Now, you move the pictures in the same way you saw them on the screen.
3. If child gives incorrect response again, #2 above is repeated up to two additional times
(or a total of 4 trials).
4. If child fails all 4 trials, test will discontinue.
Test Sequences:
Children ages 3-4 are presented with two trials of a 6-step sequence.
Read the screen: Now we are going to play the game with more pictures. This time you will see
how to Play in the Park (Form A); Go to the Fair (Form B); Work on the Farm (Form C).
Continue.
Test Item (Trial 1):
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Form A: Play in the Park Form B: Go to the Fair Form C: Work on the farm
1. Open a picnic basket • Take the pony out of the barn • Dig a hole
2. Lay out the blanket • Put the saddle on the pony • Plant the tomatoes
3. Sit on the blanket • Go for a pony ride • Water the tomatoes
4. Put a coin in the duck • Put the hot dog in a bun • Put up a fence
food machine • Spread mustard on the hot dog • Get some paint
5. Get the duck food • Eat the hot dog • Paint the fence
6. Feed the ducks
how to Play in the Park (Form A); Go to the Fair (Form B); Work on the Farm (Form C). Now, you
move the pictures in the same way you saw them on the screen.
finished?” Ask this of the child. If child says YES, touch and hold the YES button. If the child says NO,
touch any of the pictures and the pop-up will disappear. If no picture is moved out of a gray box, the pop-
up will continue to be on the screen. The pop-up will close if a picture is moved back to the yellow box
and will reappear each time all pictures have been placed in gray boxes.
Read the screen: Now you will see again how to Play in the Park (or Go to the Fair or Work on the
Farm). Everyone has to do this more than once.
Continue.
As the pictures are presented, an audio recording will say appropriate labels (same as Trial 1; see above).
how to Play in the Park (or Go to the Fair or Work on the Farm).Now, you move the pictures in
the same way you saw them on the screen.
Logic:
Test will terminate after the two test sequences have been presented.
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C.2.6.2 Picture Sequence Memory Test Instructions Ages 5-6
The test begins with a Title Screen: NIH Toolbox PSM 5-6 Form A, B or C. At the bottom of the screen
is a button Touch and Hold Here to Continue. Touch and hold that button to begin the test.
teach you how to move the pictures on this screen. When finished reading, touch the button at the

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on the screen.
Continue.
The next screen begins the practice sequences. There are two practice sequences. The child has four
trials to complete each sequence. If the child succeeds in four trials or less, the next practice sequence
or test sequence is presented. If the child fails all four trials of either practice sequence, the test is
discontinued.
Say: Now, you will see how to Have a Birthday Party. When finished reading, touch the button at the
As pictures are presented, an audio recording will say the appropriate labels:

Next, frost it.
how to Have a Birthday Party. Now, you move the pictures in the same way you saw them on the
screen.
Logic:
• If child gives correct response, Practice sequence 2, Go Camping, will be presented.
• If child gives incorrect response, Have a Birthday Party will be presented again with an
audio recording saying Let’s try that again. After the pictures are presented and as the
• If child gives incorrect response again, #2 above is repeated up to two additional times (or
a total of 4 trials).
• If child fails all 4 trials, test will discontinue.
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Say: That’s right. Now, you will see how to Go Camping. When finished reading, touch the button at
the bottom of the screen that says Touch and Hold Here to Continue.
First, put up the tent.

Then, go for a hike.
Then, catch a fish.
And last, roast a marshmallow.
how to Go Camping. Now, you move the pictures in the same way you saw them on the screen.
Logic:
1. If child gives correct response, Test Item will be presented.
2. If child gives incorrect response, Go Camping will be repeated with an audio recording saying,
Let’s try that again. After the pictures are presented and as the pictures are scrambled, an
audio recording will say: That’s how to Go Camping. Now, you move the pictures in the same
way you saw them on the screen.
3. If child gives incorrect response again, #2 above is repeated up to two additional
times (or a total of 4 trials).
Test Sequences:
Children ages 5-6 will be presented with two trials of a 9-step sequence.
how to Play in the Park (Form A); Go to the Fair (Form B); Work on the Farm (Form C). When finished
reading, touch the button at the bottom of the screen that says Touch and Hold Here to Continue.
Test Item (Trial1): As the pictures are presented, an audio recording will say appropriate labels:
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Form A: Play in the park Form B: Go to the fair Form C: Work on the farm
• Fly a kite 1. Get a hot dog • Put the cow in the barn
• Play in the sand 2. Go for a pony ride • Drive the tractor
• Go down the slide 3. Pet the sheep • Feed the pig
• Pull the wagon 4. Win a dog show • Load the cart
• Draw on the side walk 5. Go on a ride • Peel the corn
• Pet the dog 6. Get some tickets • Chop some wood
• Feed the ducks 7. Get some ice cream • Collect the eggs
• Push the swing 8. Play a game • Put the blanket on the horse
• Smell a flower 9. Milk a cow • Plant the tomatoes
Read the screen: Now you will see again how to how to Play in the Park (Form A); Go to the Fair
(Form B); Work on the Farm (Form C). Everyone has to do this more than once. When finished
reading, touch the button at the bottom of the screen that says Touch and Hold Here to Continue.
Test Item (Trial 2): As the pictures are presented, an audio recording will say appropriate labels (same
as Trial 1; see above).
Logic:
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C.2.6.3 Picture Sequence Memory Test Instructions Age 7
The test begins with a Title Screen: NIH Toolbox PSM 7 Form A, B or C. At the bottom of the screen is
a button Touch and Hold Here to Continue. Touch and hold that button to begin the test.
teach you how to move the pictures on this screen.
Continue.
After the child demonstrates understanding of this step, touch the button at the bottom of the screen that
says Touch and Hold Here to Continue.

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on the screen.
Continue.
The next screen begins the two practice sequences. The child has four trials to complete each sequence.
If the child succeeds in four trials or less, the next practice sequence or test sequence is presented. If
the child fails all four trials of either practice sequence, the test is discontinued.
Say: Now, you will see how to Have a Birthday Party. When finished reading, touch the button at the

Next, frost it.
After the pictures are presented and as the pictures are scrambled, an audio recording will say:
That’s how to Have a Birthday Party. Now, you move the pictures in the same way you saw them
on the screen.
Logic:
• If child gives correct response, Practice sequence 2, Go Camping, will be presented.
• If child gives incorrect response, Have a Birthday Party will be presented again with an
audio recording saying Let’s try that again. After the pictures are presented and as the
• If child gives incorrect response again, #2 above is repeated up to two additional times (or
• If child fails all 4 trials, test will discontinue.
Say: That’s right. Now, you will see how to Go Camping. When finished reading, touch the button at
the bottom of the screen that says Touch and Hold Here to Continue.
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Then, catch a fish.
If child gives correct response, Test Items will be presented.
If child gives incorrect response, Go Camping will be repeated with an audio recording saying Let’s try
that again. After the pictures are presented and as the pictures are scrambled, an audio recording will
say: That’s how to Go Camping. Now, you move the pictures in the same way you saw them on the
screen.
Logic:
1. If child gives incorrect response again, #2 above is repeated up to two additional times (or
Test Sequences:
Children age 7 will be presented with two test trials: one with a 15-step sequence and the other with an
18-step sequence.
Continue.
Test Item (Trial1):
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1. Fly a kite 16. Get a hot dog • Put the cow in the barn
2. Play in the sand 17. Go for a pony ride • Drive the tractor
3. Go down the slide 18. Pet the sheep • Feed the pig
4. Pull the wagon 19. Win a dog show • Load the cart
5. Swing on the monkey bars 20. Watch the rodeo • Put the carrots in the basket
6. Lay out the blanket 21. Catch a pig • Pick the fruit
7. Play catch 22. Judge the cake • Fix the fence
8. Catch a butterfly 23. See a puppet theater • Cut the sheep’s wool
9. Kick the ball 24. Take a picture of a clown • Collect the honey
10. Take the baby for a walk 25. Look at the babies
• Shovel out the barn
11. Draw on the sidewalk 26. Go on a ride
• Peel the corn
12. Pet the dog 27. Get some tickets
• Chop some wood
13. Feed the ducks 28. Get some ice cream
• Collect the eggs
14. Push the swing 29. Play a game
30. • Put the blanket on the horse
15. Smell a flower Milk a cow
• Plant the tomatoes
Read the screen: Now we’re going to do the same pictures with some more pictures added.
Everyone is asked to do this more than once. When finished reading, touch the button at the bottom
of the screen that says Touch and Hold Here to Continue.
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• Fly a kite • Get a hot dog • Put the cow in the barn
• Play in the sand • Go for a pony ride • Drive the tractor
• Go down the slide • Pet the sheep • Feed the pig
• Pull the wagon • Win a dog show • Load the cart
• Swing on the monkey • Watch the rodeo • Put the carrots in the basket
bars • Catch a pig • Pick the fruit
• Lay out the blanket • Judge the cake • Fix the fence
• Play catch • See a puppet theater • Cut the sheep’s wool
• Catch a butterfly • Watch a tractor pull • Cut the wheat
• Ride a bike • Play in the band • Herd the goats
• Row the boat • Go on a hay ride • Put up the scarecrow
• Read a book • Take a picture of a • Collect the honey
• Kick the ball clown • Shovel out the barn
• Take the baby for a • Look at the babies • Peel the corn
walk • Go on a ride • Chop some wood
• Draw on the sidewalk • Get some tickets • Collect the eggs
• Pet the dog • Get some ice cream • Put the blanket on the horse
• Feed the ducks • Play a game • Plant the tomatoes
• Push the swing • Milk a cow
• Smell a flower
how to how to Play in the Park (Form A); Go to the Fair (Form B); Work on the Farm (Form C). Now,
you move the pictures in the same way you saw them on the screen.
When all pictures have been placed in gray boxes, a pop-up will appear on the screen, “Are you finished?”
Ask this of the child. If child says YES, touch and hold the YES button. If the child says NO, touch any of
the pictures and the pop-up will disappear. If no picture is moved out of a gray box, the pop-up will continue
to be on the screen. The pop-up will close if a picture is moved back to the yellow box and will reappear
each time all pictures have been placed in gray boxes.
Logic:
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C.2.6.4 Picture Sequence Memory Test Instructions Age 8+
If the participant has difficulty dragging the pictures across the screen, during the demonstration
sequence, practice sequences, or the actual test sequences, he/she may point and the examiner will
move the pictures in the way the participant indicates. The examiner should ensure the participant
completely understands how the process will work and can say something like the following: You
point to the picture you want to move, then point to the gray box where you want to move it. I’ll move
it there for you.
The test begins with a Title Screen: NIH Toolbox PSM 8+ Form A, B or C. At the bottom of the screen
is a button Touch and Hold Here to Continue. Touch and hold that button to begin the test.
teach you how to move the pictures on this screen.
Continue.
After the participant demonstrates understanding of this step, touch the button at the bottom of the
screen that says Touch and Hold Here to Continue.

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on the screen.
Continue.
The next screen begins the one practice sequence for these ages. The participant has four trials to
complete the sequence. If the participant succeeds in four trials or less, the test sequences are presented.
If the participant fails all four trials of the practice sequence, the test is discontinued.
Practice Sequence:
Say: Now, you will see how to Go Camping. When finished reading, touch the button at the bottom of
the screen that says Touch and Hold Here to Continue.

Then, catch a fish.
finished?” Ask this of the participant.
If participant says YES, touch and hold the YES button. If the participant says NO, touch any of the
pictures and the pop-up will disappear. If no picture is moved out of a gray box, the pop-up will continue
to be on the screen. The pop-up will close if a picture is moved back to the yellow box and will reappear
each time all pictures have been placed in gray boxes.
Logic:
• If participant gives correct response, Test Item will be presented.
• If participant gives incorrect response, Go Camping will be repeated with an audio recording saying
Let’s try that again. After the pictures are presented and as the pictures are scrambled, an audio
recording will say: That’s how to Go Camping. Now, you move the pictures in the same way you saw
them on the screen.
• If participant gives incorrect response again, #2 above is repeated up to two additional
times (or a total of 4 trials).
• If participant fails all 4 trials, test will discontinue.
Test Sequences:
Participants ages 8+ will be presented with two trials: one with a 15-step sequence and the other with an
18-step sequence.
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Continue.
Test Item (Trial1): As the pictures are presented, an audio recording will say appropriate labels:
1. Fly a kite • Get a hot dog • Put the cow in the barn
2. Play in the sand • Go for a pony ride • Drive the tractor
3. Go down the slide • Pet the sheep • Feed the pig
4. Pull the wagon • Win a dog show • Load the cart
5. Swing on the monkey bars • Watch the rodeo • Put the carrots in the basket
6. Lay out the blanket • Catch a pig • Pick the fruit
7. Play catch • Judge the cake • Fix the fence
8. Catch a butterfly • See a puppet theater • Cut the sheep’s wool
9. Kick the ball • Take a picture of a clown • Collect the honey
10. Take the baby for a walk
• Look at the babies • Shovel out the barn
11. Draw on the sidewalk
• Go on a ride • Peel the corn
12. Pet the dog
• Get some tickets • Chop some wood
13. Feed the ducks
• Get some ice cream • Collect the eggs
14. Push the swing
• Play a game • Put the blanket on the horse
15. Smell a flower
• Milk a cow • Plant the tomatoes
finished?” Ask this of the participant. If participant says YES, touch and hold the YES button. If the
participant says NO, touch any of the pictures and the pop-up will disappear. If no picture is moved out
of a gray box, the pop-up will continue to be on the screen. The pop-up will close if a picture is moved
back to the yellow box and will reappear each time all pictures have been placed in gray boxes.
Read the screen: Now we’re going to do the same pictures with some more pictures added.
Everyone is asked to do this more than once. When finished reading, touch the button at the bottom
of the screen that says Touch and Hold Here to Continue.
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Test Item (Trial 2): As the pictures are presented, an audio recording will say appropriate labels:
• Fly a kite • Get a hot dog • Put the cow in the barn
• Play in the sand • Go for a pony ride • Drive the tractor
• Go down the slide • Pet the sheep • Feed the pig
• Pull the wagon • Win a dog show • Load the cart
• Swing on the monkey • Watch the rodeo • Put the carrots in the
bars • Catch a pig basket
• Lay out the blanket • Judge the cake • Pick the fruit
• Play catch • See a puppet theater • Fix the fence
• Catch a butterfly • Watch a tractor pull • Cut the sheep’s wool
• Ride a bike • Play in the band • Cut the wheat
• Row the boat • Go on a hay ride • Herd the goats
• Read a book • Take a picture of a clown • Put up the scarecrow
• Kick the ball • Look at the babies • Collect the honey
• Take the baby for a walk • Go on a ride • Shovel out the barn
• Draw on the sidewalk • Get some tickets • Peel the corn
• Pet the dog • Get some ice cream • Chop some wood
• Feed the ducks • Play a game • Collect the eggs
• Push the swing • Milk a cow • Put the blanket on the
• Smell a flower horse
• Plant the tomatoes
how to Play in the park (Form A); Go to the fair (Form B); Work on the farm (Form C).
Now, you move the pictures in the same way you saw them on the screen. When all pictures have
been placed in gray boxes, a pop-up will appear on the screen, “Are you finished?” Ask this of the
participant. If participant says YES, touch and hold the YES button. If the participant says NO, touch any
of the pictures and the pop-up will disappear. If no picture is moved out of a gray box, the pop-up will
continue to be on the screen. The pop-up will close if a picture is moved back to the yellow box and will
reappear each time all pictures have been placed in gray boxes.
Logic:
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C.2.7 NIH Toolbox Oral Reading Recognition Test
The NIH Toolbox Oral Reading Recognition Test is a measure of reading decoding skills. These skills
are part of what are considered crystalized abilities, abilities that are dependent on past learning and
exposure to other cultural experiences. To accomplish this, the iPad is paired with a wireless keyboard
on which the examiner indicates whether the participant’s response is correct or not.

III. iPad
IV. Bluetooth wireless keyboard
V. Pronunciation guide
1. Go to the Settings app of the iPad and make sure Bluetooth is turned on.
2. Make sure the keyboard is in discovery mode by pressing the round button at the top
right end of the keyboard and the small green light to the left of the button begins
flashing.
3. Select the keyboard when it appears on the My Devices list on the iPad.
4. When a pop up window appears on the iPad screen, follow the instructions and enter
the required code on the keyboard.
The usual keyboard on the iPad will not work when the external keyboard is working. To turn off the
external keyboard, press the round button at the top right end of the keyboard, move at least 15 meters
from the iPad with the keyboard, or touch the “information” button  on the iPad and touch “forget this
device.”
Using the Keyboard
Once the participant pronounces a letter or word, the examiner checks a pronunciation key and types 1
if the pronunciation is correct or 0 if the response is incorrect. After choosing 1 or 0, the examiner
presses the spacebar to move on to the next word or letter.
Ctrl + Shift on the Keyboard is equivalent to the gesture used to STOP an administration on the iPad.
Like the iPad, when Ctrl + Shift is entered on the keyboard, a login screen will pop up and ask for the
password of the user who started the assessment. As described earlier, three options will appear:
resume, skip, and stop.
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In this task, the participant is asked to read and pronounce letters and words as accurately as possible.
For the youngest children, the initial items may require them to identify the letters in an array with three
symbols or to identify a specific letter in an array of four letters. In such cases, an audio file will play,
instructing the participant to point out the answer on the iPad screen; the examiner will score the item
accordingly using the keyboard, as with all other items. The administration is individualized using a
computerized adaptive (CAT) format. This task is intended for participants 7 years and older, although
it can be administered to children as young as age 3, as appropriate.
The test uses age (for participants younger than 18) and education (for participants age 18 and older)
to determine which items it initially presents. There is an override in the participant information screen.
If an examiner feels that a participant should begin the test at a level higher or lower than that
determined by his/her education and age, the examiner should use this feature. One set of
instructions is used for all participants.
Each participant will see a series of letters and words presented one at a time on the computer screen.
Items are presented in order of difficulty – the computer adjusts the difficulty level of items depending
on the participant’s performance. The number of items presented will depend on age and performance;
for most participants, the measure will last approximately 3 minutes and will contain about 25 items.
The computer will administer each item one by one, in an untimed fashion, until the test is completed.
The measure cannot be self-administered; an examiner must record whether each response is correct.
After the participant pronounces a letter or word, the examiner checks a pronunciation key as needed
and types 1 if the pronunciation is correct or 0 if the response is incorrect. After choosing 1 or 0, the
examiner presses the spacebar to move on to the next word or letter. The examiner can go back and
change one prior answer by touching the left arrow on the keyboard and choosing a new answer and
then touching the spacebar to activate the next item.
Testing is automatically discontinued if a participant makes seven consecutive errors.
Note: It is essential that the examiner thoroughly review and master the pronunciation guide before
administering this test. The examiner should not rely on his/her understanding of word
pronunciations based on previous experience. Instead, the examiner must adhere to this guide for
all item scoring. At the same time, while scoring is strict, it should take into consideration
difficulties in pronunciation that can be attributed to dialect or articulation; to the extent that these
difficulties are consistent throughout the testing, they should be accepted as correct pronunciations
by the examiner.
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C.2.7.1 Oral Reading Recognition Test Instructions Age 3+
iPad and have the keyboard and word list and pronunciation guide easily accessible for scoring
participant responses.
The task is introduced with the Title Screen: NIH Toolbox OR 3+.
To check the Bluetooth connection, the examiner is asked at the bottom of the page to: Press
Spacebar to Continue. Touching the spacebar begins the test. If the spacebar does not work, try re-
pairing the keyboard or changing the batteries in the keyboard.
Say: Now I’m going to show you some letters and some words. I want you to read each
letter or word out loud. Read each one loud enough so that I can hear you. Some will be
easy and some will be hard. Don’t worry if you don’t know the word or its meaning – just
read it out loud the best you can. Let’s begin.
Press spacebar to continue.
When the first item appears, say: Tell me, what is this letter/word? (Say whichever is appropriate. This
prompt can be repeated as many times as needed.)
After participant answers, the examiner checks a pronunciation guide as needed and types 1 if the
participant’s pronunciation is correct or 0 if the response is incorrect.
After choosing 1 or 0, the examiner presses the spacebar to move on to the next word or letter.
Pressing the spacebar registers the choice in the scoring program; until the spacebar is pressed, the
examiner may change his/her choice without having to go back.
If the participant says: I don’t know this one or I can’t read it, say: It is OK if you don’t know the word
or what it means – just try to read it as best you can. This prompt can be used to reassure participants
if they refuse to read the letters/words. If, after prompting, a participant refuses to offer a response, mark
the item incorrect (0) and press the spacebar to move on to the next item.
NOTE: The examiner can go back one previous item to change an answer if the participant self-
corrects or the examiner realizes a scoring error was made. To do this, press the left arrow on the
keyboard, then press 1 or 0 to indicate the score for the item to be corrected item. Then, press the
spacebar and the next item will be presented (this may or may not be the same word/letter seen
before the left arrow was pressed).
NOTE: For the youngest children, the initial items may require them to identify the letters in an array
with three symbols or to identify a specific letter in an array of four letters. In such cases, an audio
file will play, instructing the participant to point out the answer on the iPad screen; the examiner will
score the item accordingly using the keyboard, as with all other items.
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C.2.8 Oral Symbol Digit Test
The NIH Toolbox Oral Symbol Digit Test is a brief and easily administered measure of processing
speed designed for ages 8 and above. It consists of a “key” of 9 unique symbols, each paired with a
number from 1-9, and requires the participant to look at a long series of symbols without numbers and
call out orally which number belongs with each symbol. The participant must call out the numbers
sequentially and as quickly as possible, looking at a (preferably) laminated sheet, while the examiner
records the participant’s response as correct/incorrect directly on the iPad using the touch screen. The
test results are automatically scored. The participant has 120 seconds to call out as many correct
numbers as he/she can, in order, without skipping any. The test is designed for ages 8 and above, but
at the researcher’s/examiner’s discretion, it may be administered to children younger than 8.
I. iPad
II. Laminated sheet containing key and nine practice items on one side and the key and test
items on the other side
C.2.8.1 Oral Symbol Digit Test Instructions

General Instructions:
1. The introductory instructions, practice instructions, and the instructions for completing the test items
will be printed on the iPad screen and are to be read by the examiner. The test items themselves are
on the laminated sheet that is provided by the examiner to the participant, while the examiner marks
each item called out correctly on the iPad screen. The examiner initiates the test and the iPad timer by
touching the START TEST button.
2. The iPad should face toward the examiner. The participant does not interact with the iPad during this
test.
3. All items with the correct answers (144 in total) will appear in “scoring boxes” on the iPad screen. As
the participant calls out answers to each item (in order), the examiner touches each the item to mark it
as correct, or leaves it unmarked if it is incorrect. Touching the item on the iPad screen adds a check
mark by the number. If the examiner makes an error, he/she should simply touch the item again to
deselect it.
4. As needed, the examiner should slide his/her finger on the screen to scroll to more items and to
score each of them (for legibility, not all 144 items appear on the iPad screen at once, but all are
accessible via scrolling; this is manageable because the participant must answer items in the order
presented, without skipping any).
5. The participant has 120 seconds to answer as many items as he/she can, in order, without skipping
any. At the end of 120 seconds, a tone will sound to alert the examiner and participant that time is up.
The examiner should instruct the participant to stop. The examiner may continue recording any items
that need to be scored before touching NEXT to end the test.
NIH Toolbox Oral Symbol Digit Test Instructions Age 8+

The task is introduced with the Title Screen: NIH Toolbox OSD 8+. At the bottom of the screen is a
Ages 8-85+:
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The first screen will be an instructional screen to be read by the examiner. The examiner should put the
laminated sheet in front of the participant, with the side with the practice items (SIDE 1) facing up. The
examiner should point to this sheet and
SAY: Please look at the symbols at the top of the page. Each symbol is paired with a number.
(Point to the pairs and show how they are arranged across the row.)
SAY: Now look here. (Point to the row of symbols without numbers.) Here there are symbols but no
numbers. I would like you to tell me the number that goes with each symbol like this: You see
this symbol (point to the O), it is matched with the number 6 (point to the key), so you would say
or tell me “6”; this next symbol (point to the X), is paired with an 8 (point), so you would say or
tell me 8. Does this make sense? Answer any questions if the participant is unsure.
SAY: Now you try the rest of the row for practice. Remember to say each number out loud so
that I can hear you.
The examiner should provide feedback after each response, indicating whether the response is correct
with, “That’s right,” or correcting the response when it is wrong. Repeat practice items as necessary
until the participant can answer them correctly.
After the participant has completed the practice row,
SAY: Good. Now that you know how to do this, I am going to ask you to do some more.
SAY: Now I will turn over this sheet and you will see more rows which have symbols, but not the
numbers that go with them.
At the bottom of the screen is a button Touch and Hold Here to Continue. Touch and hold that button to
continue to the next screen.
The examiner should turn over the laminated sheet to SIDE 2 to reveal the test items.
SAY: When I tell you to begin, I want you to do the rows on this page the same way – tell me the
number that goes with each symbol. I want you to work as quickly as you can without skipping
any of the boxes or making mistakes. When you are finished with the first row, move on to the
next one. Continue working until you hear a bell sound on this iPad and I tell you to stop. If you
make a mistake, just tell me the correct answer and keep going. Ready?
At the bottom of the screen is a button Touch and Hold Here to Continue. Touch and hold that button to
move to the next screen, where you will begin the test.
On the next screen, the examiner should touch START TEST and immediately,
SAY: Begin.
As soon as the examiner touches START TEST, a timer will begin counting down from 120 seconds at
the bottom of the screen (for the examiner’s information only). All items with the correct answers (144 in
total) will appear in “scoring boxes” on the iPad screen. As the participant calls out answers to each
item, the examiner should touch each item to mark it as correct, or leaves it unmarked if it is incorrect.
Touching the item on the iPad screen adds a check mark by the number. If the examiner makes an
error, he/she should simply touch the item again to deselect it.
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As needed, the examiner should slide his/her finger on the screen to scroll to more items and to score
each of them (for legibility, not all 144 items appear on the iPad screen at once, but all are accessible
via scrolling).
At the end of 120 seconds, a tone will sound to alert the examiner and participant that time is up. The
examiner should instruct the participant to stop. After the tone, a window will pop up on the iPad screen
that says: “Are you finished marking the correct answers from the participant? If you choose no, please
touch NEXT when you are finished marking correct answers.” The examiner should touch YES if
he/she has finished scoring items. Otherwise, the examiner should touch NO and continue recording
any items that need to be scored. When finished scoring, the examiner should touch NEXT to end the
test.
C.2.9 Auditory Verbal Learning Test (Rey)

The NIH Toolbox Auditory Verbal Learning Test (Rey) is an adaptation of the RAVLT, a brief and easily
administered measure of immediate memory and verbal learning. It consists of a list of 15 unrelated
words (see list below) that are presented by audio recording on the iPad to the participant at a rate of
one word per second. For the Toolbox version of this test, the list is repeated three times. All
instructions for the participant appear on the iPad screen and are read by the examiner to the
participant. In addition, the examiner records the participant’s responses directly on the iPad using the
touch screen, and the test results are automatically scored. The test is designed for ages 8 and above,
but at the researcher’s/examiner’s discretion, it may be administered to children younger than 8.
I. iPad
C.2.9.1 Auditory Verbal Learning Test (Rey) Instructions

1. The introductory instructions as well as the instructions for each set of words to be played will be
printed on the iPad screen and are to be read by the examiner. The words (stimuli) themselves are pre-
recorded and will play from the iPad when the examiner touches PLAY.
2. The iPad should face toward the examiner. The participant does not interact with the iPad during this
test.
3. All 15 words will appear in “scoring boxes” on the iPad screen, below the instructions. Once the
audio recording of the words has finished playing, the examiner touches each word the participant says
that corresponds to one of the words on the list (there is no score and no penalty for words stated that
were not part of the list). Touching the word on the iPad screen adds a check mark by the word. If the
examiner makes an error, he/she should simply touch the word again to deselect it.
4. Once the participant has finished recalling words for a trial and the examiner has completed the
scoring of the items, the examiner touches NEXT to go to the next trial (or to end the test, if on trial 3).
Note that NEXT will not be active on the screen until the audio recording has finished playing all 15
words in a given trial.
5. Before beginning, make sure the volume is loud enough so that participants can hear the pre-
recorded presentation of the words.
The list of words used for the test is: Drum, Curtain, Bell, Coffee, School, Parent, Moon, Garden, Hat,
Farmer, Nose, Turkey, Color, House, River.
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C.2.9.1.1 Instructions for ages 8+
At the top of the screen it will say “Trial 1.”
SAY: Now we are going to do some memory for words. You will hear a list of words from this iPad.
Listen carefully; when the voice stops, you are to repeat back as many words as you can remember. It
does not matter in what order you repeat them. Just try to remember as many words as you can.
Ready?
Below these instructions, there are instructions to the examiner, which read: “Press PLAY to start. Then
touch each word the participant says (touch again to deselect if needed).”
When the participant is ready, the examiner should touch the PLAY button, and the audio recording of
the word list will commence from the iPad.
As soon as the participant starts repeating words, the examiner should record each word the participant
says by touching the box next to the word on the iPad screen. This requires the examiner to work fast
and keep pace with the participant. If the participant says a word that is not on the list, the examiner
should ignore it.
After the participant finishes naming words from the first trial, the examiner should touch the NEXT
button and administer the list two more times with the following instructions:
Trial 2:
Say: Once again you will hear the same words from this iPad, and again when the voice stops, I want
you to tell me as many words as you can remember, whether or not you said them before. Ready?
The examiner should touch the PLAY button on the screen, and the iPad will start the audio with the list
of words.
says by touching the box next to the word on the iPad screen. If the participant says a word that is not
on the list, the examiner should ignore it.
After the participant finishes naming words from the second trial, the examiner should touch the NEXT
button and administer the list two more times with the following instructions:
Trial 3:
Say: Again, you will hear the same words, and once again when the voice stops, I want you to tell me
as many words as you can remember, whether or not you said them before. Ready?
The examiner should touch the PLAY button on the screen, and the iPad will start the audio with the list
of words.
says by touching the box next to the word on the iPad screen. If the participant says a word that is not
on the list, the examiner should ignore it.
The test ends automatically after three trials.
C.3 Emotion Domain
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Emotion refers to any strong feeling, as of joy, sorrow, or fear. Emotion is an affective state of
consciousness in which joy, sorrow, fear, hate, or the like is experienced, as distinguished from
cognitive and volitional states of consciousness. Emotions can be negative and distressing, or positive
emotions can be reflections of well-being in our lives, and positive social relationships can buffer stress
and enhance health.
Emotion Domain Framework
NIH Toolbox Emotion consists of four subdomains: Psychological Well Being, Social Relationships,
Stress & Self Efficacy, and Negative Affect. Each subdomain includes narrower constructs that are
measured through appropriate versioned surveys for Adults (over 18); ages 13-17; ages 8-12 (self and
parent-report) and ages 3-7 (parent-report only).
Emotion
Psychological Social Stress & Self-

Negative Affect
Well-Being Relationships Efficacy
Perceived
Positive Affect Social Support Fear
Stress
Life
Companionship Self-Efficacy Sadness
Satisfaction
Meaning &
Social Distress Anger
Purpose
Positive Social
Development
Psychological Well-Being (PWB) includes both hedonic and eudaimonic components. Hedonic
constructs are more subjective and experiential and emphasize pleasure and positive affect
(happiness, serenity, and cognitive engagement). Eudaimonic well-being is more evaluative and
emphasizes fulfillment and purpose (e.g., meaning, life satisfaction).
Social Relationships refers to the interactions between two or more people. Dimensions of social
relationships include structure, extent and quality.
Stress & Self-Efficacy describes individual perceptions about the nature of events and their
relationship to the perceived coping resources of an individual.
Negative Affect refers to unpleasant feelings or emotions, which exist on a continuum ranging from
common and normal feelings of sadness, fear, and anger to more extreme feelings along the same
continuum.
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C.3.1 Emotion Constructs
NIH Toolbox Emotion constructs are defined below.
Psychological Well- Definition

Being
Positive Affect Feelings that reflect a level of pleasurable engagement with the
environment such as happiness, joy, excitement, enthusiasm, and
contentment.
General Life Satisfaction One’s cognitive evaluation of life experiences; whether people like their
lives or not. Life satisfaction includes both general (e.g., my life is going
well) and domain-specific (e.g., I am satisfied with my family life)
aspects.
Meaning and Purpose Characterized by the extent to which people feel their life matters or
makes sense.
Social Relationships Definition
The extent to which an individual views his/her social relationships as
available to provide aid in times of need or when problems arise. It
includes instrumental and emotional social support. Emotional Support:
Social Support perception that people in one’s social network are available to listen to
one’s problems with empathy, caring and understanding. Instrumental
Support: perception that people in one’s social network are available to
provide material or functional aid in completing daily tasks.
Characterized by self-reported perceptions of the availability of friends
or companions with whom to interact or affiliate (i.e., friendship) and
Companionship
perceptions that one is alone, lonely or socially isolated (i.e.,
loneliness).
The extent to which an individual perceives his/her daily interactions as
Social Distress
negative or distressing.
Positive Social Characterized by parents' evaluation of their children's empathic
Development behaviors.
Stress & Self Efficacy Definition
Individual perceptions about the nature of events and their relationship
Perceived Stress
to the values and coping resources of an individual.
A person’s belief in their capacity to manage their functioning and have
Self-Efficacy
control over meaningful events.
Negative Affect Definitions
Fear Characterized by symptoms of anxiety that reflect autonomic arousal
and perceptions of threat.
Sadness Distinguished by low levels of positive affect and comprised of
symptoms that are primarily affective (poor mood) and cognitive
(negative perceptions of self, the world, and the future) indicators of
depression.
Anger Characterized by attitudes of hostility and cynicism and is often
associated with experiences of frustration impeding goal-directed
behavior.
Emotion Measure Formats

Each emotion measure is administered in either a computerized adaptive testing (CAT) or fixed form
(FF) format:
CATs – Emotion CATs begin with a standard item (specific to that measure) and then select items to
administer based on a respondent’s previous answers. An algorithm is utilized to determine which item
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should be administered next. NIH Toolbox instruments, which use CAT as an administration method,
are often referred to as Banks. CATS are usually 4-6 items long.
Fixed Forms (FFs) - fixed length form with all items administered in a set (sequential) order.
Self- versus proxy-report

All Emotion items are presented in a self-report (i.e., the respondent answers questions about
him/herself) or in a proxy (parent)-report (i.e., the respondent answers questions about someone else)
format:
Pediatric self-report –measures completed by the participant, ages 8-17.
Adult self-report –measures completed by adult participants 18+ years of age.
Parent report –measures completed by parents for children ages 3-12.
Time to administer
All individual emotion measures take approximately 1-2 minutes to complete.
Emotion Batteries
The NIH Toolbox App includes 5 preset batteries: NIH Toolbox Emotion Battery (age 18+), NIH
Toolbox Emotion Battery (ages 8-12), NIH Toolbox Emotion Battery (ages 13-17), NIH Toolbox
Emotion Parent Report Battery (ages 3-7), and NIH Toolbox Emotion Parent Report Battery (ages 8-12)
Users wishing to select specific measures or create custom batteries can find the complete list of
available measures here.
There are two versions of NIH Toolbox Emotion instructions: NIH Toolbox Emotion Instructions
(Adult/Child) and NIH Toolbox Emotion Instructions (Parent Report). When using individual instruments
to set up an assessment or build a custom battery, users must select the correct version to precede
Emotion instruments. All preset Emotion batteries include appropriate instructions.
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C.3.2 General Instructions
The participant answers emotion measures at his/her own speed. An examiner need not be involved.
After a question is answered, the screen advances automatically to the next question. All measures for
the youngest age group (3-7) are parent (proxy) report measures. On these measures, the proxy
(parent or guardian) responds to questions about the child according to how he/she thinks the child is
doing.
For 8-12 year old children, measures come in both self- and parent-report versions. For ages 13+, only
self-report measures are available.
C.3.3 NIH Toolbox Emotion Age-Specific Instructions and Instruments
Self-report and parent-report instruments have slightly different instructions on the screen; these are
given below:
NIH Toolbox Participant Instructions for Self-Report Measures (Children and Adults):
“On the next screens, we will ask you questions about your thoughts, feelings and behaviors.
Read each question carefully and answer as well as you can. There is no right or wrong answer,
only what is true for you and describes your thoughts, feelings, and behaviors.
“Select an answer by touching your answer choice on the screen. After you make your choice,
the computer will automatically go on to the next question. If you want to change your answer,
touch the GO BACK button to return to the question, then touch a different answer choice.”
A button at the bottom of the screen says: “Touch and Hold Here to Continue.”
The content and order of measures within the self-report batteries are shown in the following tables.
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C.3.3.1 NIH Toolbox Emotion Battery (age 18+)
Instrument name CAT or # of Items in

Fixed Form
NIH Toolbox Emotion Instructions (Adult/Child) --
NIH Toolbox Positive Affect CAT Age 18+ v2.0 CAT
NIH Toolbox General Life Satisfaction CAT Age 18+ v2.0 CAT
NIH Toolbox Meaning and Purpose CAT Age 18+ v2.0 CAT
NIH Toolbox Emotional Support FF Age 8+ v2.0 8
NIH Toolbox Instrumental Support FF Age 18+ v2.0 8
NIH Toolbox Friendship FF Age 8+ v2.0 8
NIH Toolbox Loneliness FF Age 8+ v2.0 5
NIH Toolbox Perceived Rejection FF Age 8+v2.0 8
NIH Toolbox Perceived Hostility FF Age 8+ v2.0 8
NIH Toolbox Self-Efficacy CAT Age 18+ v2.0 CAT
NIH Toolbox Perceived Stress FF Age 18+ v2.0 10
NIH Toolbox Fear-Affect CAT Age 18+ v2.0 CAT
NIH Toolbox Fear-Somatic Arousal FF Age 18+ v2.0 6
NIH Toolbox Sadness CAT Age 18+ v2.0 CAT
NIH Toolbox Anger-Affect CAT Age 18+ v2.0 CAT
NIH Toolbox Anger-Hostility FF Age 18+ v2.0 5
NIH Toolbox Anger-Physical Aggression FF Age 18+ v2.0 5
NIH TB Meaning and Purpose FF Age 18+ 8
NIH TB Positive Affect FF Age 18+ 15
NIH TB Anger-Affect FF Age 18+ v1.1 5
NIH TB Fear-Affect FF Age 18+ 6
NIH TB Apathy FF Age 18+ 7
NIH TB General Life Satisfaction FF Age 18+ ?
NIH TB Positive Affect FF Ages 8-17 v2.0 9
NIH TB Domain-Specific Life Satis. FF Age 18+ 13
C.3.3.2 NIH Toolbox Emotion Battery (Ages 8-12)

Fixed Form
NIH Toolbox Positive Affect FF Ages 8-12 v2.0 9
NIH Toolbox General Life Satisfaction FF Ages 8-12 v2.0 5
NIH Toolbox Perceived Rejection FF Age 8+ v2.0 5
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NIH Toolbox Self-Efficacy CAT Ages 8-12 v2.0 CAT
NIH Toolbox Anger-Affect FF Ages 8-17 v2.0 5
NIH Toolbox Sadness FF Ages 8-17 v2.0 8
NIH Toolbox Fear FF Ages 8-17 v2.0 8
NIH TB Emotion Control FF Ages 8-17 10
NIH TB Maternal Relationship FF Ages 8-17 3
NIH TB Paternal Relationship FF Ages 8-17 3
NIH TB Emotion Control Parent Rpt FF Ages 8-12 10
NIH TB Sadness Parent Rpt FF ages 8-12 11
NIH TB Domain-Specific Life Satis. FF Ages 8-17 7
C.3.3.3 NIH Toolbox Emotion Battery (Ages 13-17)

Fixed Form
NIH Toolbox Positive Affect CAT Ages 13-17 v2.0 CAT
NIH Toolbox General Life Satisfaction CAT Ages 13-17 v2.0 CAT
NIH Toolbox Perceived Rejection FF Age 8+ v2.0 5
NIH Toolbox Self-Efficacy CAT Ages 13-17 v2.0 CAT
NIH Toolbox Perceived Stress FF Ages 13-17 v2.0 10
NIH Toolbox Anger-Affect FF Ages 8-17 v2.0 5
NIH Toolbox Sadness FF Ages 8-17 v2.0 8
NIH Toolbox Fear FF Ages 8-17 v2.0 8
NIH TB General Life Satisfaction FF Age 13-17 ?
NIH Toolbox Emotion Instructions (Parent Report):

“On the next screens, you will see questions about your child’s feelings and behaviors. Read
each question carefully and answer as best you can. Please consider each question by itself
and choose an answer that you believe honestly shows how your child feels and acts.
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Select an answer by touching the answer choice on the screen. After you make your choice, the
computer will automatically go on to the next question. If you want to change your answer,
A button at the bottom of the screen says: “Touch and Hold Here to Continue.”
The content and order of measures within the parent report batteries are shown in the following tables.
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C.3.3.4 NIH Toolbox Emotion Parent Report Battery (ages 3-7)
Instrument name CAT or # of

Items in Fixed
Form
NIH Toolbox Emotion Instructions(Parent Report) --
NIH Toolbox Positive Affect Parent Report CAT Ages 3-7 v2.0 CAT
NIH Toolbox General Life Satisfaction Parent Report FF Ages 3-12 v2.0 5
NIH Toolbox Positive Peer Interaction Parent Report FF Ages 3-12 v2.0 4
NIH Toolbox Social Withdrawal Parent Report FF Ages 3-12 v2.0 4
NIH Toolbox Peer Rejection Parent Report FF Ages 3-12 v2.0 9
NIH Toolbox Empathic Behaviors Parent Report CAT Ages 3-12 v2.0 CAT
NIH Toolbox Fear-Over Anxious Parent Report FF Ages 3-7 v2.0 6
NIH Toolbox Fear-Separation Anxiety Parent Report FF Ages 3-7 v2.0 7
NIH Toolbox Sadness Parent Report FF Ages 3-7 v2.0 7
NIH Toolbox Anger Parent Report FF Ages 3-7 v2.0 9
NIH TB Pos. Parent Relat. Parent Rpt FF Ages 3-12 5
NIH TB Sibling Rejection Parent Rpt FF Ages 3-12 9
NIH TB Positive Affect Parent Rpt FF Ages 3-12 9
NIH TB Dom-Spec Life Satis Parent Rpt FF Ages 3-12 7
C.3.3.5 NIH Toolbox Emotion Parent Report Battery (ages 8-12)
Instrument name CAT or # of

Items in Fixed
Form
NIH Toolbox Emotion Instructions (Parent Report) --
NIH Toolbox Positive Affect Parent Report CAT Ages 8-12 v2.0 CAT
NIH Toolbox General Life Satisfaction Parent Report FF Ages 3-12 v2.0 5
NIH Toolbox Perceived Stress Parent Report CAT Ages 8-12 v2.0 CAT
NIH Toolbox Self-Efficacy Parent Report CAT Ages 8-12 v2.0 CAT
NIH Toolbox Positive Peer Interaction Parent Report FF Ages 3-12 v2.0 4
NIH Toolbox Social Withdrawal Parent Report FF Ages 3-12 v2.0 4
NIH Toolbox Peer Rejection Parent Report FF Ages 3-12 v2.0 9
NIH Toolbox Empathic Behaviors Parent Report CAT Ages 3-12 v2.0 CAT
NIH Toolbox Fear Parent Report CAT Ages 8-12 v2.0 CAT
NIH Toolbox Sadness Parent Report CAT Ages 8-12 v2.0 CAT
NIH Toolbox Anger Parent Report CAT Ages 8-12 v2.0 CAT
When using preset batteries, correct instructions will be included automatically. When using
individual instruments to set up an assessment or build a custom battery, users must select the correct
version to precede Emotion instruments. There are two versions of NIH Toolbox instructions: NIH
Toolbox Emotion Instructions (Adult/Child) and NIH Toolbox Emotion Instructions (Parent Report).
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152
C.3.4 Emotion measures available in the NIH Toolbox App
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*CATs are typically 4-6 items in length
C3.4.1 Supplemental Emotion Measures

Supplemental emotion measures represent instruments that are not part of any of the preset
(standard) Emotion batteries. Supplemental measures include alternate formats (e.g. fixed
length form versus CAT) of standard emotion instruments as well as additional measures.
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CAT or # of Items
Instrument Name in Fixed Form
NIH TB Meaning and Purpose FF Age 18 + 8
NIH TB Positive Affect FF Age 18+ 15
NIH TB Positive Affect FF Ages 8-12 9
NIH TB Anger-Affect FF Age 18+ v1.1 5
NIH TB Fear-Affect FF Age 18+ 29
NIH TB Sadness FF Age 18+ 8
NIH TB Emotion Control Parent Rpt FF Ages 8-12 10
NIH TB Sadness Parent Rpt FF ages 8-12 11
NIH TB General Life Satisfaction FF Age 13-17 5
NIH TB General Life Satisfaction FF Age 18+ 4
NIH TB Domain-Specific Life Satis. FF Age 18+ 13
Many NIH Toolbox Emotion Measures include items drawn from existing measures. These were
used with their author’s permission. Sources of items can be found on the NIH Toolbox website
http://www.nihtoolbox.org/WhatAndWhy/Emotion/Acknowledgements/Pages/default.aspx
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C.4 Motor Domain
Motor function is the ability to use and control muscles and movements. Motor performance includes
voluntary control of both fine and gross motor functions including dexterity, strength, balance,
locomotion and endurance. Motor performance also requires the interaction of multiple body systems
including the nervous, muscular, cardiovascular, and sensory-perceptual systems.
Motor
Definition
Constructs
Dexterity is the coordination of small muscle movements that occur
in body parts, such as the ability to coordinate fingers to manipulate
Dexterity
objects quickly and accurately. It is measured by the NIH Toolbox 9-
Hole Pegboard Dexterity Test
Strength refers to a muscle's ability to generate force against
physical objects. Measuring handgrip assesses how strong one’s
Strength
hand grip is, which in turn provides a good approximation of overall
muscle strength. It is measured by the NIH Toolbox Grip Strength
Test
Balance refers to the ability to orient the body in space, maintain an
upright posture under both static and dynamic conditions, and move
Balance
and walk without falling. It is measured by the NIH Toolbox Standing
Balance Test.
Locomotion refers to the act of moving from one place to the other
place, reflecting ambulation ability including walking distance,
Locomotion velocity, and quality of the gait over different environments and
ground surfaces. It is assessed by the NIH Toolbox 4-Meter Walk
Gait Speed Test.
Endurance refers to how long a person can perform a particular
activity requiring cardiopulmonary function, biomechanical and
Endurance neuromuscular function at a particular intensity. Endurance
assesses overall cardiovascular endurance. It is measured by the
NIH Toolbox 2-Minute Walk Endurance Test
Time to
Motor Battery Instruments Ages Administer
(minutes)
NIH Toolbox 9-hole Pegboard Dexterity Test 3-85 4
NIH Toolbox Grip Strength Test 3-85 3
NIH Toolbox Standing Balance Test 3-85 7
NIH Toolbox 4 Meter Walk Gait Speed Test 7-85 3
NIH Toolbox 2-Minute Walk Endurance Test 3-85 4
The “Time to Administer (minutes)” column gives users an idea of how long each test might take;
however, please note that testing times could vary based on how prepared the test administrator is
going into the session, individual differences among participants, as well as other unplanned activities
that may occur during testing.
C.4.1 NIH Toolbox 9-Hole Pegboard Dexterity Test
The NIH Toolbox 9-Hole Pegboard Dexterity Test assesses fine motor dexterity. Dexterity is a central
component of hand function and relates to both the speed and accuracy of hand movements during the
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manipulation of objects. In this task, a nine-hole pegboard is used to assess dexterity and the data are
recorded using an on-screen timer on the iPad. The protocol includes one practice and one timed trial
with each hand.
VI. iPad
VII. Jamar® (or Rolyan) 9-Hole Peg Test kit
VIII. Jamar® 9-Hole Peg Test kit replacement pegs
Set-up:
1. Place the pegboard on the table, positioning it in front and at the center of the participant’s
body. Place the cup with the 9 pegs on the side of the hand being tested.
2. The participant may use the hand not being tested to stabilize the board.
3. Make sure the hand being tested is flat on the table (palm down) until the administrator says
Go.
4. Use a placemat or piece of rubber shelving to keep the pegboard from slipping on the table.
This is a suggestion, but is not required.
5. All instructions as well as data screens are on the iPad.
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C.4.1.1 9-Hole Pegboard Test Instructions for Ages 3+
The task is introduced with the Title Screen: NIH Toolbox 9-Hole Pegboard Dexterity Test 3+. At the
bottom of the screen is a button Touch and Hold Here to Continue. Touch and hold that button to
begin the test.
Follow the set-up instructions outlined on the screen:
Place the pegboard on the table, positioning it in front and at the center of the participant’s body. Place
the cup with the 9 pegs on the side of the hand being tested. The hand not being tested can be used to
stabilize the board. The hand being tested should be flat on the table (palm down) until the administrator
says Go.
At the bottom of the screen is a button Touch and Hold Here to Continue. Touch and hold that button
to begin the test.
Say: In this activity we are going to see how fast you work with your hands. You are going to use
your RIGHT (or LEFT, as appropriate) hand only (point to hand if needed for understanding), and then
you will do it again with your LEFT (or RIGHT, as appropriate) hand (point to hand if needed).
Show participant the pegboard and say: This is a pegboard and these are the pegs. All the pegs are
the same. Pick up the pegs one at a time using your (RIGHT (or LEFT, as appropriate) hand only
(point to hand if needed). Put them in the holes one at a time until all 9 holes are filled. Then take
them all out, one at a time, like this.
The examiner demonstrates the task and says as he/she is working: The pegs can be put in the holes
or taken out in any order. I have extra pegs, so if you drop a peg, don’t go after it. I’ll put in another
one.
to begin the test.
Dominant Hand Practice:
Have participant start with his/her hand flat on table beside pegboard. Remind participant that non-
dominant hand can be used to stabilize board and continue: Let’s practice with your RIGHT (or LEFT,
as appropriate) hand (point to hand if needed). You can use your other hand to hold the board in
place.
At the bottom of the screen, it says: Right (or Left as appropriate) Hand Practice and there is a timer
with START and RESET buttons.
Say: Are you ready? 3, 2, 1, Go!
Make sure to touch the START button as soon as you say ‘GO’. As participant is placing the final peg,
say: And take them out.
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Touch the STOP button as soon as the final peg is placed back in the cup. After timer stops, touch the
NEXT button and confirm your choice in the pop-up window.
There is a RESET button if, for some reason, the participant needs to start again. If this happens,
the examiner should touch RESET and confirm his/her choice in the pop-up window. Start the
trial over again, removing all the pegs before starting.
Test Trial (dominant hand):
Say: Now I will time how fast you can do this. Pick up the pegs one at a time using only your
RIGHT (or LEFT, as appropriate) hand. Put them in the holes, one at a time, until all 9 holes are
filled. Then take them all out, one at a time. The pegs can be put in the holes or taken out in any
order. Remember to work as fast as you can.
Have participant start with his/her hand flat on table beside pegboard.
At the bottom of the screen, it says: Right (or Left as appropriate) Hand Trial and there is a timer with
START and RESET buttons.
the examiner should touch RESET and confirm your choice in the pop-up window. Start the trial
over again, removing all the pegs before starting.
Non-Dominant Hand Practice:
Turn pegboard around so that the cup with the pegs is on the side of the non-dominant hand.
Read: Now we are going to do the same thing with your other hand. Again, pick up the pegs one
at a time using only your LEFT (or RIGHT, as appropriate) hand (point to hand if needed). Put them
in the holes, one at a time, until all 9 holes are filled. Then take them all out, one at a time. The
pegs can be put in the holes or taken out in any order.
Have participant start with his/her hand flat on table beside pegboard. Remind participant that dominant
hand can be used to stabilize board and continue: Let’s practice. Remember, you can use your other
hand to hold the board in place.
At the bottom of the screen, it says: Right (or Left as appropriate) Hand Practice and there is a timer
with START and RESET buttons.

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Test Trial (non-dominant hand):
Say: Now I will time how fast you can do this. Pick up the pegs one at a time using only your LEFT
(or RIGHT, as appropriate) hand. Put them in the holes, one at a time, until all 9 holes are filled.
Then take them all out, one at a time. The pegs can be put in the holes or taken out in any order.
Remember to work as fast as you can.
Have participant start with his/her hand flat on table beside pegboard.
At the bottom of the screen, it says: Right (or Left as appropriate) Hand Trial and there is a timer with
START and RESET buttons.
Test ends.
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C.4.2 NIH Toolbox Grip Strength Test
This is a measure of upper extremity muscle strength that makes use of a dynamometer. It was
originally adapted from the protocol of the American Society of Hand Therapy. The results are
recorded on the iPad screen.
IX. iPad
X. Jamar® Plus+ (or Rolyan) Digital Hand Dynamometer
Set-up:
Before beginning, be sure the dynamometer is turned on

The handle for gripping the dynamometer is adjustable, but should be initially set at the notch second
closest to the unit (touch information button for picture).
Before each trial, press RESET button and then TEST button on the dynamometer to record the grip
strength (force)
Support the dynamometer for the participant and ensure the participant is holding the arm being tested
next to but not touching his/her side, with elbow bent at 90 degrees.
Procedure:
The testing involves one practice trial with each hand, followed by one test trial with each hand. The
alternation allows the hand to recover strength between exertions.
C.4.2.1 Grip Strength Test Instructions Ages 3+
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The task is introduced with the Title Screen: NIH Toolbox Grip Strength Test 3+. At the bottom of the
screen is a button Touch and Hold Here to Continue. Touch and hold that button to begin the test.
Follow the set-up instructions outlined in the Grip Strength Introduction and on the iPad screen,
specifically:
1. Before beginning, be sure to turn on the dynamometer.
2. The hand for gripping the dynamometer is adjustable, but should be set at the notch second
closest to the unit (touch information button for picture).
3. Before each trial, press RESET button and then TEST button on the dynamometer to record the
grip strength (force).
4. Have the participant sit down in the chair so his/her feet are on the floor or foot plate of the
wheelchair and his/her knees are at a 90-degree angle.
5. Support the dynamometer for the participant and ensure that the participant is holding the arm
being tested at a 90-degree angle, next to but not touching his/her body.
Touch the button at the bottom of the screen that says Touch and Hold Here to Continue.
Say: We will use this machine (show dynamometer) to measure how strong your hands are. You
will squeeze the handle 2 times (one practice and one test trial) with each hand while your arm is
against your side (see note below) and your elbow is bent like this (demonstrate 90 degrees). The
handle won’t move, but the machine will show how hard you squeezed. (Press RESET and TEST,
then squeeze to demonstrate). See? (Show participant the force measurement.) Do you have any
questions?
After the participant demonstrates understanding, touch the button at the bottom of the screen that says
Touch and Hold Here to Continue.
“Against your side” means next to but not touching your body.
Practice (dominant hand):

Press RESET and TEST.
Say: Let’s practice with your RIGHT (or LEFT as appropriate) hand (point to hand if needed). When I
say ‘squeeze,’ I want you to squeeze the handle hard, but not as hard as you can. (Support
dynamometer.)
Continue: Ready? 3-2-1-squeeze. After 3-4 seconds, say: Stop.
Press RESET and TEST on dynamometer before continuing.
Practice (non-dominant hand):
Continue: Now we’re going to practice with your RIGHT (or LEFT as appropriate) hand (point to hand
if needed). When I say ‘squeeze,’ I want you to squeeze the handle hard, but not as hard as you
can. (Support dynamometer.)
Continue: Ready? 3-2-1-squeeze. After 3-4 seconds, say: Stop.
Press RESET and TEST on dynamometer before continuing.
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Test Trial (dominant hand):
Say: Now we’re going to test each hand, beginning with your RIGHT (or LEFT as appropriate) hand.
When I say ‘squeeze,’ this time I want you to squeeze the handle as hard as you can.
Support dynamometer during testing. Continue: Ready? 3-2-1-squeeze! Harder, harder, harder! After
3-4 seconds, say: Stop.
Record force to nearest tenth of a pound on the iPad screen.
Press RESET and TEST on dynamometer before next trial.
Touch Next button to record the data and move to non-dominant hand test trial.
Test Trial (non-dominant):

Say: Now we’re going to test your LEFT (or RIGHT as appropriate) hand (point to hand if needed).
When I say ‘squeeze,’ this time I want you to squeeze the handle as hard as you can.
Support dynamometer during testing. Continue: Ready? 3-2-1-squeeze! Harder, harder, harder! After
3-4 seconds, say: Stop.
Record force to nearest tenth of a pound on the iPad screen.
Touch Next button to record the data and end the test.
Turn off dynamometer when testing is completed.
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C.4.3 NIH Toolbox Standing Balance Test
This task is designed to assess postural sway and to determine participants’ vestibulo-spinal function.
Children ages 3-6 are asked to complete the first four poses; participants, ages 7-85 years, are asked
to complete all five poses.
There are exclusion rules for participants who are not tested by a trained professional. These are:
• Weight over 250 pounds
• Diabetes, depending on comfort
• Joint replacement(s), depending on comfort
• Previous stroke
• Parkinson’s disease
• Dizziness/vertigo
• Fallen in the last 6 months more than one time not as a result of an accident
• Multiple sclerosis
• Macular degeneration
• Glaucoma
• Cataracts
• Pregnancy

XI. iPad
XII. iPod Touch (5th generation or later)
XIII. The BalancePod app, installed on the iPod Touch. BalancePod is available at no additional cost
through the App Store. Get BalancePod here.
XIV. Griffin Survivor protective case or similar
XV. AIREX Balance Pad Elite
XVI. Scott Gait Belt w/Velcro
XVII. Sanitary booties
Set-up:
This task requires the examiner to set up the equipment before the participant arrives.
Upon launching the BalancePod App, the iPod will display a dashboard with two buttons at the bottom of
the screen. One button: Standing Balance Test Info directs the user to an informational screen that
includes a single text file that scrolls up and down. The second button: Start a Standing Balance Test
directs the user to the connection server that communicates between the iPod accelerometer and the
iPad test administration.
The screen is illustrated below:
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iPod / iPad synchronization
A participant’s movement (sway) is measured by an iPod that is enclosed in a protective case. The
iPod is attached to the gait belt by a clip, as shown below. It is critical that the iPod be inserted in the
protective case in the correct orientation with the home button toward the floor as shown (not upside-
down).
• Open the Standing Balance Test on the iPad and turn on the iPod as described above.
• Open the BalancePod App and select Start a Standing Balance Test if you have not already done
so.
• On the iPad, select the name of the iPod with which you want to pair the iPad; when they are
connected, the DONE button becomes activated. Select DONE.
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• A green band will appear at the top of both the iPad and the iPod when they are paired and
communicating.
• As the iPad and iPod are being calibrated, a gray button tells you the status: calibrating or
calibrated.
• When the word CALIBRATED appears on the iPad screen, touch the Touch and hold here to
continue button to start the test.
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• It is possible but not common that the calibration might need to be repeated after the participant
is prepared. If this happens, the following screen appears. Touch the re-connect button until the
word CALIBRATED appears on the iPad screen and continue as described above.
Preparing the Participant:

Ask permission from the participant to put the gait belt on him/her. Strap the Velcro gait belt onto the
participant so that the belt is fit tightly around the pelvis with the top of the belt at the top of the hip
bones. The handles of the belt should be positioned behind the participant and may be used by the
examiner in case of loss of balance by the participant. If the participant has a smaller waist, it may be
necessary to wrap the belt a second time around the participant (or to use a smaller gait belt). If so, be
sure the accelerometer is still positioned appropriately.
For children ages 3-6, the iPod is worn on the back of the belt; when possible, the handles of the gait
belt should be positioned on whichever side of the child is closest to where the examiner will be
positioned.
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For participants ages 7-85, the iPod is attached on the front of the belt (approximately where a typical
belt buckle would be located). The handles should be to the back of the participant.
Participants are to stand in their bare/stocking feet (no shoes). They can wear paper booties if they
wish. Place a chair placed behind the participant if rest is needed between trials.
The examiner should stand behind the participant (to the side of participants ages 3-6) to be ready to
prevent the participant from falling. During testing, the iPad should be placed on a table in close
proximity to the examiner.
It is crucial that the iPad is never greater than a few feet (certainly less than 15’) away from the iPod
and gait belt unit the participant is wearing during testing. While it might be easiest to hold the iPad
during testing, in the event that a participant requires help after a stumble or fall, the examiner might
have to drop the iPad and endanger its integrity.
Each participant will be given up to two trials to be successful. Use the following guidelines to stop a
trial, as any of these are evidence that the participant is no longer holding the pose and has failed the
trial:
1. If the arms come off of the chest
2. If the knees bend
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3. If the feet move out of original position (move or swivel out or are lifted)
4. If the participant bends forward at the waist (more than 45 degrees). If this happens, the examiner will
have to support the participant with the belt
5. If the participant opens his/her eyes during an eyes-closed pose (poses 2 and 4)
6. If the participant says something like: “I cannot do that” or “I do not feel safe trying that”
As needed throughout testing, remind the participant that he/she can step out of the pose,
if he/she is feeling unsafe or unable to hold the pose.
A second trial should be attempted if the first trial is not successfully completed; the examiner should
stand close to the participant to prevent actual falls. Some participants will succeed on the second trial,
even if they failed the first trial (particularly on the foam or in the tandem pose).
Each pose and trial is presented on a separate iPad screen.
These screens always have: a description of the pose, which trial, and three buttons: Start, Stop/Fail
and Pass.
The Start and Stop/Fail are enabled at the beginning of each trial; the Pass button is only enabled after
data is received from the balance pod. A tone is played on the iPod once 50 seconds have elapsed.
All the buttons are disabled during the interval between the 50 seconds tone and when data are
received on the iPad.
Whenever the PASS or the STOP/FAIL button is touched, a pop-up window asking for confirmation of
the choice will appear. The examiner must confirm his/her choice.
The task order is always the same:
• Pose 1: flat surface, feet together, eyes open

• Pose 2: flat surface, feet together, eyes closed
• Pose 3: on foam, feet together, eyes open
• Pose 4: on foam, feet together, eyes closed
• Pose 5: flat surface, tandem stance, eyes open (only given to participants ages 7+)
Throughout the task, the computer may invoke Discontinue Rules automatically. These are:
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Rule 1: If the participant cannot successfully complete either trial of pose 1, the test will be discontinued.
Rule 2: If the participant cannot successfully complete either trial of pose 2, he/she will not be asked to
perform any more poses with eyes closed (i.e., will not be administered pose 4).
Rule 3: If the participant cannot successfully complete either trial of pose 3, the test will skip ahead to
pose 5.
A re-connect button is always enabled should the devices become disconnected.
Age specific instructions:
Standing Balance Test Instructions Ages 3-6

Standing Balance Test Instructions Ages 7+
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C.4.3.1 Standing Balance Test Instructions Ages 3-6
The task is introduced with the following Title Screen: NIH Toolbox Standing Balance Test 3-6. At the
bottom of the screen is a button Touch and hold here to continue. Touch and hold that button to
begin the test.
Participants are to stand in their bare/stocking feet (no shoes, but paper booties can be offered).
While putting the belt and accelerometer on the participant, say: This is a test of your balance. There
are as many as 4 different poses that you will be asked to do. During each pose, you will be asked
to stand as steady as possible for 50 seconds. You will have a second chance if you cannot hold
the position for 50 seconds. Between each set of poses, you may rest in the chair if needed.
Please try to do your best. I will demonstrate how I want you to stand before each pose.
Explain that the iPod on the belt is used to measure balance and ask permission to put on the belt or ask
the participant to help. The belt should fit tightly around the pelvis. For ages 3-6, the iPod should be
placed on the back of the belt and when possible the handles on the belt should be on the participant’s
side.
A sheet of paper with an attractive picture or a large X should be placed on the wall at the participant’s
eye level. For the eyes open poses, the participant will be asked to focus on this picture or X. The
participant is positioned one meter away from the wall, directly in front of the picture or X.
The examiner should proceed through each of the poses with the participant until the test is
completed. After each trial or pose is completed, the examiner should ask: Are you ready for the
next one?
If the participant says NO or otherwise indicates that he/she needs to rest, say: Please sit in this
chair to rest. The examiner should note the time the participant begins resting; a maximum of
one minute of rest is permitted.
Every 15 seconds or so, the examiner should ask: Are you ready to continue? If the participant
indicates that he/she is ready, proceed with the next trial or pose. If the participant is not ready,
wait and ask again in another 15 seconds.
If the participant is not ready by the end of the one-minute rest period, the test should be
discontinued. In such a case, the examiner should say: Let’s go on to another activity.
As needed throughout the testing, the examiner should remind the participant that he/she can
step out of the pose if he/she is feeling unsafe or unable to hold the pose.
When the participant is ready for testing, the examiner should touch and hold the button at the bottom of
the screen to advance to the test itself.
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Pose 1 Screen: Flat surface, feet together, eyes open
The examiner should demonstrate the pose describing what he/she is doing as it is being done.
The participant’s turn is next; the examiner should ask the participant to stand in the desired position,
saying: Please stand with your feet together (heels and balls of feet touching) and as still as
possible with your eyes open and with your arms crossed on your chest, like this (demonstrate).
Focus on the X shown on the wall in front of you. Ready? After the participant assumes the position,
the examiner touches the START button and says: Go.
The examiner should check the participant’s posture. The iPad screen will display the elapsed time of
the trial so the examiner can easily see it while assuring the safety of the participant. In addition, an
audible tone will play when 50 seconds has elapsed, alerting both the examiner and the participant that
the trial has ended.
Choose STOP/FAIL if the participant did not successfully complete the trial for any reason.
If the first trial is failed for any reason, start the second trial of this pose; the examiner should say: Let’s
try that one again. Please stand with your feet together (heels and balls of feet touching) and as
still as possible with your eyes open and with your arms crossed on your chest, like this
(demonstrate). Focus on the X shown on the wall in front of you. Ready? The examiner touches the
START button and says: Go. Again, choose STOP/FAIL if the participant did not successfully complete
the trial for any reason.
After 50 seconds of elapsed trial time, a tone will sound. After a few more seconds, the examiner will be
able to touch the PASS or STOP/FAIL button.
the choice will appear. The examiner must confirm his/her choice to move onto the next trial.
Note: If a participant fails both trials of Pose 1, the test is terminated.
Once the participant successfully completes a trial, say: Are you ready for the next one?
Proceed with the next pose or allow the participant to rest, following the procedures noted above. If
participant fails trial 2, the discontinue rule is invoked; say: We are done with this activity.
Pose 2 Screen: Flat surface, feet together, eyes closed: is the same as Pose 1, except this time the
participant’s eyes are closed.
possible with your eyes closed and with your arms crossed on your chest, like this (demonstrate).
Ready? After the participant assumes the position, the examiner touches the START button and says:
Go.
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the trial so the examiner can easily see it while assuring the safety of the participant.
If the first trial is failed for any reason, start he second trial of this pose; the examiner should say: Let’s
try that one again. Please stand with your feet together (heels and balls of feet touching) and as
still as possible with your eyes closed and with your arms crossed on your chest, like this
(demonstrate). Ready? The examiner touches the START button and says: Go. Again, choose
STOP/FAIL if the participant did not successfully complete the trial for any reason.
After participant completes one or both trials, say: Are you ready for the next one? Proceed with the
next pose or allow the participant to rest, following the procedures noted above.
Pose 3 Screen: Foam surface, feet together, eyes open
The examiner should pick up the blue pad and place it on the floor one meter in front of the picture on
the wall. The examiner should demonstrate the pose describing what he/she is doing as it is being done.
saying: Please step onto the foam and put your feet together (heels and balls of feet touching) and
stand as still as possible with your eyes open and your arms crossed on your chest, like this
(demonstrate). Focus on the X shown on the wall in front of you. Ready? After the participant
assumes the position, the examiner touches the START button and says: Go.
try that one again. Please step onto the foam and put your feet together (heels and balls of feet
touching) and stand as still as possible with your eyes open and your arms crossed on your
chest, like this (demonstrate). Focus on the X shown on the wall in front of you. Ready? The
examiner touches the START button and says: Go. Again, choose STOP/FAIL if the participant did not
successfully complete the trial for any reason.
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Pose 4 Screen: Foam surface, feet together, eyes closed: is the same as Pose 3 except that the
participant’s eyes are closed. The examiner should demonstrate the pose describing what he/she is doing
as it is being done.
stand as still as possible with your arms crossed on your chest, and then close your eyes, like
this (demonstrate for participant). Ready? After the participant assumes the position, the examiner
touches the START button and says: Go.
touching) and stand as still as possible with your arms crossed on your chest, then close your
eyes, like this (demonstrate for participant). Ready? The examiner touches the START button and says:
Go. Again, choose STOP/FAIL if the participant did not successfully complete the trial for any reason.
When the participant has completed pose 4, say: We are done with this activity.
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C.4.3.2 Standing Balance Test Instructions Ages 7+
The task is introduced with the following Title Screen: NIH Toolbox Standing Balance Test 7+. At the
bottom of the screen is a button Touch and hold here to continue. Touch and hold that button to
begin the test.
Participants are to stand in their bare/stocking feet (no shoes, but paper booties can be offered).
While putting the belt and iPod on the participant, say: This is a test of your balance. There are as
many as 5 different poses that you will be asked to do. During each pose, you will be asked to
stand as steady as possible for 50 seconds. You will have a second chance if you cannot hold
the position for 50 seconds. Between each set of poses, you may rest in the chair if needed.
Please try to do your best. I will demonstrate how I want you to stand before each pose.
Explain that the iPod on the belt is used to measure balance and ask permission to put on the belt or ask
the participant to help. The belt should fit tightly around the pelvis and the handles of the belt should be
positioned to the back of the participant. For ages 7 and older, the iPod is placed on the front of the belt.
A sheet of paper with an attractive picture or large X should be placed on the wall at the participant’s eye
level. For the eyes open poses, the participant will be asked to focus on this picture. The participant is
positioned one meter away from the wall, directly in front of the picture.
The examiner should proceed through each of the poses with the participant until the test is
completed.
After each trial or pose is completed, the examiner should ask: Are you ready for the next one?
If the participant says NO or otherwise indicates that he/she needs to rest, say:
Please sit in this chair to rest. The examiner should note the time the participant begins resting;
a maximum of one minute of rest is permitted.
Every 15 seconds or so, the examiner should ask: Are you ready to continue? If the participant
indicates that he/she is ready, proceed with the next trial or pose. If the participant is not ready,
wait and ask again in another 15 seconds.
If the participant is not ready by the end of the one-minute rest period, the test should be
discontinued. In such a case, the examiner should say: Let’s go on to another activity.
As needed throughout the testing, the examiner should remind the participant that he/she can
step out of the pose if he/she is feeling unsafe or unable to hold the pose.
When the participant is ready for testing, the examiner should touch and hold the button at the bottom of
the screen to advance to the test itself.
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Pose 1 Screen: Flat surface, feet together, eyes open
possible with your eyes open and with your arms crossed on your chest, like this (demonstrate for
participant). Focus on this X shown on the wall in front of you. Ready?
After the participant assumes the position, the examiner touches the START button and says: Go.
the trial so the examiner can easily see it while assuring the safety of the participant. In addition, an
audible tone will play when time has elapsed, so the both the examiner and participant know the trial has
ended. Choose STOP/FAIL if the participant did not successfully complete the trial for any reason.
If a second trial is needed, start the second trial of this pose; the examiner should say: Let’s try that one
again. Please stand with your feet together (heels and balls of feet touching) and as still as
possible with your eyes open and with your arms crossed on your chest, like this (demonstrate).
Focus on the X shown on the wall in front of you. Ready?
The examiner touches the START button and says: Go. Again, choose STOP/FAIL if the participant did
not successfully complete the trial for any reason. After 50 seconds of elapsed trial time, a tone will sound.
After a few more seconds, the examiner will be able to touch the PASS or STOP/FAIL button.
the choice will appear. The examiner must confirm his/her choice to move on to the next trial.
Note: If a participant fails both trials of Pose 1, the test will be terminated.
Once the participant successfully completes a trial, say: Are you ready for the next one?
Proceed with the next pose or allow the participant to rest, following the procedures noted above. If
participant fails trial 2, the discontinue rule is invoked; say: We are done with this activity.
Pose 2 Screen: Flat surface, feet together, eyes closed: the same as Pose 1, except this time the
participant’s eyes are closed. The examiner should demonstrate the pose describing what he/she is doing
as it is being done.
Ready?
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After the participant assumes the position, the examiner touches the START button and says: Go. The
examiner should check the participant’s posture and that the eyes remain closed. The iPad screen will
display the elapsed time of the trial so the examiner can easily see it while assuring the safety of the
participant.
Choose STOP/FAIL if the participant did not successfully complete the trial for any reason. If the first
trial is failed for any reason, start the second trial of this pose; the examiner should say: Let’s try that
one again. Please stand with your feet together (heels and balls of feet touching) and as still as
Ready?
not successfully complete the trial for any reason. After 50 seconds of elapsed trial time, a tone will sound.
After a few more seconds, the examiner will be able to touch the PASS or STOP/FAIL button. Whenever
the PASS or the STOP/FAIL button is touched, a pop-up window asking for confirmation of the choice
will appear. The examiner must confirm his/her choice to move onto the next trial.
Pose 3 Screen: Foam surface, feet together, eyes open
The examiner should pick up the blue pad and place it on the floor one meter in front of the picture on
the wall. The examiner should demonstrate the pose describing what he/she is doing as it is being
done.
saying: Please step onto the foam and put your feet together (heels and balls of feet touching)
and stand as still as possible with your eyes open and your arms crossed on your chest, like
this (demonstrate). Focus on the X shown on the wall in front of you. Ready?
examiner should check the participant’s posture. The iPad screen will display the elapsed time of the trial
so the examiner can easily see it while assuring the safety of the participant.
Choose STOP/FAIL if the participant did not successfully complete the trial for any reason. If the first
trial is failed for any reason, start the second trial of this pose; the examiner should say: Let’s try that
one again. Please step onto the foam and put your feet together (heels and balls of feet touching)
and stand as still as possible with your eyes open and your arms crossed on your chest, like this
(demonstrate). Focus on the X shown on the wall in front of you. Ready?
not successfully complete the trial for any reason. After 50 seconds of elapsed trial time, a tone will
sound. After a few more seconds, the examiner will be able to touch the PASS or STOP/FAIL button.
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Pose 4 Screen:
Foam surface, feet together, eyes closed: is the same as Pose 3 except that the participant’s eyes are
closed. The examiner should demonstrate the pose describing what he/she is doing as it is being done.
stand as still as possible with your arms crossed on your chest, and then close your eyes, like
this (demonstrate). Ready?
so the examiner can easily see it while assuring the safety of the participant. Choose STOP/FAIL if the
participant did not successfully complete the trial for any reason.
touching) and stand as still as possible with your arms crossed on your chest, then close your
eyes, like this (demonstrate). Ready? The examiner touches the START button and says: Go. Again,
choose STOP/FAIL if the participant did not successfully complete the trial for any reason.
able to touch the PASS or STOP/FAIL button. Whenever the PASS or the STOP/FAIL button is touched,
a pop-up window asking for confirmation of the choice will appear. The examiner must confirm his/her
choice to move onto the next trial.
Pose 5: Flat surface, tandem stance, eyes open:
saying: Please stand with the heel of one foot touching the toes of the other foot on the ground.
Keep them in a straight line. Stand as still as possible with your eyes open and with your arms
crossed on your chest, like this (demonstrate for participant). Before you do this, try each foot in
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front and decide for yourself which one is more comfortable. Then, focus on the X on the wall in
front of you. Ready?
so the examiner can easily see it while assuring the safety of the participant.
If the first trial is failed for any reason, start he second trial of this pose; the examiner should say: Let’s
try that one again. Please stand with the heel of one foot touching the toes of the other foot on
the ground. Keep them in a straight line. Stand as still as possible with your eyes open and with
your arms crossed on your chest, like this (demonstrate for participant). Focus on the X shown on
the wall in front of you. Ready?
not successfully complete the trial for any reason. After 50 seconds of elapsed trial time, a tone will
sound. After a few more seconds, the examiner will be able to touch the PASS or STOP/FAIL button.
When the participant has completed pose 5, say: We are done with this activity.
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C.4.4 NIH Toolbox 4-Meter Walk Gait Speed Test
This measure of gait speed is administered in an open hallway and can use part of the same course as
the 2-Minute Walk Endurance Test (See Appendix 6). The test is administered two times, both at the
participant’s normal pace. A practice trial precedes the timed trials.
The instructions are on and a timer is embedded in the iPad screen. The timing begins (START button)
when the participant steps over the starting line. The foot does not need to be flat on the floor. Timing
stops when one of the participant’s feet is completely across the end/finish line (the line at 4 meters, not
at 5 meters where the cone is).
The examiner should be positioned so that he/she can easily see when the participant steps across
each line. If necessary, walk behind and to the side of the participant as he/she walks.
Participants should not do this walk in bare feet, high-heeled or open-back shoes, sandals, or
flip-flops. Paper booties may be offered.

XVIII. iPad
XIX. Measuring tape with meters and feet
XX. Set of two cones
XXI. Walking course set up diagram
Detailed information on setting up the walking courses for the NIH Toolbox 4-Meter Walk Gait Speed
Test and 2-Minute Walk Endurance Test can be found in Appendix 6.
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C.4.4.1 4-Meter Walk Gait Speed Test Instructions Ages 7+
The task is introduced with the following Title Screen: NIH Toolbox 4-Meter Gait Speed Test 7+. At the
begin the test.
The examiner should observe how participants walk normally. If they use a cane or other walking device and
feel they need it for the walking test, they may use it. If the participant uses such a device, the examiner should
note its use.
First Screen:
The examiner should show the participant the walking course and say: This activity involves walking
from one place to another. This is our walking course (point to the course). I want you to walk to
the other end of the course at your usual speed, just as if you were walking down the street to go
to the store.
Touch and hold button for next screen.
Demonstration Screen:
The examiner explains the walk: Let me show you what I want you to do. Put both your feet together
behind this line (point to starting line). Walk all the way past the cone on the other end before you
stop.
Before the demonstration, say: 3, 2, 1, Go! Examiner should demonstrate the walk. After returning,
examiner presses Touch and hold button for next screen.
Practice Screen:
After demonstration, have the participant stand with both feet touching the start line; say: Now you try.
Remember to walk at your usual speed and keep walking until you pass the cone. When I want
you to start, I will say: 3, 2, 1, go. Do you have any questions? (Answer any questions.) Ready? 3,
2, 1, Go!
When the participant passes the cone, say: That’s good. Do you have any questions? (Answer any
questions.) Touch and hold that button for next screen.
After practice is completed, the following screens will then be presented. As below, each shows what the
examiner is to say and do.
Test Intro Screen:
Begin timing (press start/stop button) when the participant steps over (first footfall) the starting line. Stop
timing when one of the participant’s feet is completely across the end/finish line (the line at 4.0 meters –
not the line at 5.0 meters).
Position yourself so that you can easily see when the participant steps across each line. If necessary,
walk behind and to the side of the participant as he/she walks.
If the participant stumbles or tries to run, void that trial and ask the participant to do another trial. To do
this on the screen, press the RESET button to set the timer back to zero (confirming when the pop-up
screen appears). Then give the trial again following all instructions.
Test Trial 1 Screen:
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Say: This time, I am going to time you as you walk at your usual speed. Are you ready? 3, 2, 1,
Go!
Make sure to touch the START button as soon as the participant steps over the starting line.
Touch the STOP button as soon as one of the participant’s feet is completely across the finish line.
After timer stops, touch the NEXT button and confirm your choice in the pop-up window.
Test Trial 2 Screen:
Say: Now I want you to repeat the walk. Remember to walk at your usual pace and go all the way
past the cone at the other end of the course. Are you ready? 3, 2, 1, Go!
Make sure to touch the START button as soon as the participant steps over the starting line.
Touch the STOP button as soon as one of the participant’s feet is completely across the finish line.
After timer stops, touch the NEXT button and confirm your choice in the pop-up window.
If needed, have the participant rest in a chair for at least one minute before the next task.
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C.4.5 NIH Toolbox 2-Minute Walk Endurance Test
This measure of endurance can be administered to participants ages 3 to 85. It is administered in an

open hallway. The participant should be wearing comfortable shoes such as athletic shoes. A timer and
grid for marking the number of feet traversed is embedded on the iPad screen. All the instructions appear
on the iPad screen.
Participants should not do this test in bare feet, high-heeled or open-back shoes, sandals, or
flip-flops.

• iPad
• Two cones
• Chair
• Measuring tape
• Masking tape
Detailed information on setting up the walking courses for the NIH Toolbox 4-Meter Walk Gait Speed
Test and 2-Minute Walk Endurance Test can be found in Appendix 6.
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C.4.5.1 NIH Toolbox 2-Minute Walk Endurance Test Instructions Ages 3+
The task is introduced with the following Title Screen: NIH Toolbox 2-Minute Walk Endurance Test 3+.
to begin the test.
The examiner should observe how participants normally walk. If they use a cane or other walking
device and feel they need it for the walking test, they may use it. If the participant uses such a device,
the examiner should make a note of this.
First Screen: Examiner should have participant sit in a chair near the beginning of the walking course.
Introduce the task; say: This is an activity that shows how physically fit you are by seeing how far
you can walk in 2 minutes. I will ask you to walk as fast as you can until I ask you to stop. I
know this is hard for some people so don’t worry if you have to slow down or rest. If you do
stop or slow down, start walking again as soon as you feel you are ready do so.
Continue: Is there any reason you cannot do the walk? Does anything hurt or are you in pain?
What I would like here is to have you walk as far as you can in this short period of time. If
participant does not feel he/she can do this task, note this and continue with another measure.
Continue: You and I will not talk while you are walking because this might make you walk more
slowly. I will, however, let you know how much time you have to walk and when you are almost
done.
Touch and hold button to go to next screen.
Demonstration & Practice Screen: While demonstrating the first part of the task, say: Let me show you
what you are going to do. You will start with your feet behind this line (Point to starting line).
When I say ‘Go,’ you will walk back and forth around the cones as fast as you can without
running or hurting yourself.
You will begin after I say ‘Ready, 3, 2, 1, Go!’ As you pass the cone, do not stop or slow down.
When I tell you to stop, stop where you are on the path until I come to you.
Demonstrate task and say: Watch me as I show you. You see that I am walking fast but not
running and that I am not slowing or stopping when I pass the cone. Do you have any
questions? Answer questions as necessary.
Practice: Ask participant to walk course once down and back; say: Now you can practice. Walk the
path, out and back one time; go around the cone without slowing down. Ready, 3, 2, 1, Go!
When participant is finished, say: Do you have any questions? Answer any questions participant has.
Touch and hold the button to move to the next screen.
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Test Trial Screen:
• The test trial screen has a timer centered in the middle of the screen that shows
2:00 automatically when the screen appears.
• The timer has a START/STOP button and a RESET button.
• Touching START turns the button into a STOP button.
• Touching STOP activates the RESET button, meaning START cannot be
activated again until RESET is touched.
Once the RESET button is touched, a pop-up will appear that asks the examiner to confirm the RESET
and if confirmed, the timer will be reset.
1. Resetting also presents the initial instructions at the top of the screen again.
2. Directly below the timer is the ‘lap/turn’ button that records the number of times a user has
passed a cone and next to the lap/turn button is a ‘+’ button and below that is ‘-‘ button.
3. The + and - buttons allow the user to add or subtract laps in case an error was made.
4. A counter actively keeps track of how many times lap was touched or what the + and -
buttons added or subtracted from that total.
5. At the bottom of the screen, there is text saying: Each time the participant makes a turn
press the “Lap” button to record it and If you make a mistake press the “+” or “-“ button to
add or subtract one lap.
Below is the test trial screen:
Continue by saying: This time, I will be timing you. Remember, when I say ‘Go,’ walk back and forth
around the cones as fast as possible for 2 minutes without running or hurting yourself. Ready,
3, 2, 1, Go! Start the timer and keep track of the laps as described above.
At the same time, examiner should provide the following feedback:*
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1 minute: You are doing well. You have 1 minute to go.
*If participant is resting at one-minute reminder, encourage him/her to continue and
change statement to: You have only 1 minute left. Rest as long as you need; start
walking again as soon as you feel able to do so.
When time reads 0:15, tell the participant: In a moment, I’m going to ask you to stop. When I do,
just stop right where you are and I will come to you. When five seconds remain, examiner should
count down: 5, 4, 3, 2, 1, stop. Please stay where you are and rest.
The examiner put a piece of tape on the floor to mark where participant stopped; the tape should be
placed behind the participant’s heel.
The examiner should direct participant to sit in the chair while the examiner measures the distance
from the last cone passed to the piece of tape. The examiner should press NEXT button on the test
trial screen to submit the trial data (the laps). The Next button becomes active at the end of the trial
(when 2 minutes have elapsed). Once “Next” is pressed, the app proceeds to the screen where more
detailed measurements can be entered.
A new screen will appear. This screen is a data screen that shows the Laps that were recorded on the
previous screen and number wheels for the number of 10 feet, single feet, and inches measured after
the participant completes the two minutes.
This data entry screen is given below:
The examiner should record the distance from the last cone to where the participant stopped on this
data screen and press NEXT to submit the data. All the fields can be adjusted until NEXT is pressed.
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C.5 Sensation Domain
Sensation refers to the biochemical and neurologic process of detecting incoming nerve impulses as
nervous system activity. Sensory processes are vital to one’s level of independence in relationships
with others, academic and occupational endeavors, and activities of daily living.
Sensation &
Pain
Definition
Constructs
Pain is an unpleasant sensory and emotional experience associated with

actual or potential tissue damage, or described in terms of such damage. It
Pain is measured by the NIH Toolbox Pain Interference Survey and the NIH
Toolbox Pain Intensity Survey.
The human olfactory system allows us to detect odors, to recognize and

Olfaction discriminate odor qualities, and to identify the sources of odors in our
world. It is measured by the NIH Toolbox Odor Identification Test.
Vision is a complex sensation that provides us with a personal, conscious
representation of our surrounding environment.
Visual impairment can impose various limitations on a person’s functional
Vision ability including reading, mobility (which includes driving), visual information
processing (also called “seeing”), and visually guided motor behavior (also
called “manipulation”). It is measured by the NIH Toolbox Visual Acuity
Test.
Audition, or hearing, is the processing of sound in the environment. It is
Audition
measured by the NIH Toolbox Words-in-Noise (WIN) Test.
Taste perception, also known as gustation, arises from stimulation of taste
receptors, which are composed of epithelial cells, found most frequently on
Taste
the papillae of the tongue throughout the oral cavity. It is measured by the
NIH Toolbox Regional Taste Test.
Time to
Sensation & Pain Instruments Ages Administer
(minutes)
NIH Toolbox Pain Interference Survey 18-85 3
NIH Toolbox Pain Intensity Survey 18-85 1
NIH Toolbox Odor Identification Test 3-85 4-5
NIH Toolbox Visual Acuity Test 3-85 3
NIH Toolbox Words-in-Noise (WIN) Test 6-85 6
NIH Toolbox Regional Taste Intensity Test 12-85 6
The “Time to Administer (minutes)” column gives users an idea of how long each test might
take; however, please note that testing times could vary based on how prepared the test administrator
is going into the session, individual differences among participants, as well as other unplanned
activities that may occur during testing.
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Only the individual Sensation instruments listed above are available through the NIH Toolbox App
at this time. The Sensation Battery will be released later in 2015.
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C.5.1 NIH Toolbox Pain Interference Survey (18+) & NIH Toolbox Pain Intensity Survey
(18+)

XXII. iPad
Two instruments, NIH Toolbox Pain Interference CAT Age 18+ and NIH Toolbox Pain Intensity FF Age
18+), make up the measurement of this construct. Each is self-administered; for each, instructions are
presented on the iPad screen. Each instrument is presented separately to the participant.
Pain Intensity consists of one item asking about the participant’s level of pain in the past seven days.
Participants are asked to rate their pain on a scale from 0 (no pain) to 10 (worst imaginable pain).
NIH Toolbox Pain Interference CAT asks participants about how their experience of pain interfered with
or affected their enjoyment of various daily activities in the past seven days. The scale is computer-
adaptive and has a minimum of four questions and a maximum of 12 questions. The questions ask for
a response on a 5-point scale. Some of the items are rated: Not at all; A little bit; Somewhat; Quite a bit;
Very much; other items are rated: Never; Rarely; Sometimes; Often; Always.
Administration:
Since there is no specific introduction to the Pain Surveys, the NIH Toolbox Emotion Instructions should
be selected from the instrument list, to introduce them. These instructions read:
“On the next screens, we will ask you questions about your thoughts, feelings and behaviors.
Read each question carefully and answer as well as you can. There is no right or wrong answer,
only what is true for you and describes your thoughts, feelings, and behaviors.
Select an answer by touching your answer choice on the screen. After you make your choice,
the computer will automatically go on to the next question. If you want to change your answer,
After this introduction, the surveys are automatically presented, first with the question from the Pain
Intensity survey followed by the questions from the Pain Interference survey.
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C.5.2 NIH Toolbox Odor Identification Test
This task assesses the ability to identify various odors. Before identifying the odors, the child
participants (ages 3-9 years) are asked to identify the eight pictures that are used as answer choices.
Having identified the pictures, they are asked if they have smelled the objects or foods depicted. The
examiner needs to have an iPad, scratch ‘n’ sniff cards, and a scratcher (e.g., guitar pick) to administer
this measure.

XXIII. iPad
XXIV. NIH Toolbox Odor Identification Cards
XXV. Scratcher
For the test items, all participants (ages 3-85 years) use scratch ’n’ sniff cards. These cards are
numbered to match not only the order in which they are presented but the number on the iPad screen
as well. After scratching them, participants are asked to identify which of four pictures on the screen
matches the odor they have just smelled.
Children ages 3 to 9 are handed cards that the examiner scratched and are asked to identify five odors;
participants ages 10 and above are asked to scratch and identify nine odors.
There are two versions of the instructions: one for ages 3-9 and one for ages 10 and above. In both
versions, the participant is allowed to go back to the last item he/she attempted.
If either a child or adult participant has difficulty touching the pictures on the iPad screen, he/she
may point and the examiner may touch the iPad. When this happens, the examiner should say
something like the following to the participant: You can point to the picture you want and then
I will touch it for you. Similarly, if a participant has trouble reading picture labels, the examiner
may read the labels for him/her.
Age-specific Instructions:
NIH Toolbox Odor Identification Test Ages 3-9
NIH Toolbox Odor Identification Test Ages 10+
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C.5.2.1 NIH Toolbox Odor Identification Test Instructions Ages 3-9
The task is introduced with the following Title Screen: NIH Toolbox Odor Identification Test 3-9. At the
begin the test.
For this age group, there are two parts to the instructions: picture identification and odor
identification.
Part 1: Picture Identification:

The child is presented with a screen that shows eight pictures: Popcorn, Flower, Lemon, Play Doh,
Bubble Gum, Chocolate, Coffee, and Cinnamon. A voice on the iPad asks the child to: ‘Touch the
picture of….’
The examiner should read the screen: Now we are going to look at some pictures. I want to see if
you know what they are. At the bottom of the screen is a button Touch and Hold Here to Continue.
Touch and hold that button to begin.
Question 1: the voice on the iPad says: Touch the picture of a flower.
If correct, the voice on the iPad will say: That’s right! Or Great Job! (Alternating throughout this part of
the task).
If incorrect, the picture of a flower will flash and the voice will say: This is a flower.
The screen will change to the Flower picture and a voice on the iPad will ask: Have you ever smelled
a flower?
Touch yes or no on the screen to indicate the child’s answer, then touch NEXT at the bottom of the
screen to go on to the next item. The answer choice can be changed between No and Yes until
’Continue’ is pressed to advance to next screen. No Go Back is permitted in Picture Identification
component.
Question 2: the voice on the iPad says: Touch the picture of popcorn.
the task).
If incorrect, the picture of popcorn will flash and the voice will say: This is popcorn.
The screen will change to the Popcorn picture and a voice on the iPad will ask: Have you ever
smelled popcorn?
component.
Question 3: the voice on the iPad says: Touch the picture of a lemon.
the task).
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If incorrect, the picture of lemons will flash and the voice will say: This is a lemon.
The screen will change to the Lemon picture and a voice on the iPad will ask: Have you ever smelled
a lemon?
component.
Question 4: the voice on the iPad says: Touch the picture of Play Doh.
the task).
If incorrect, the picture of Play Doh will flash and the voice will say: This is Play Doh.
The screen will change to the Play Doh picture and a voice on the iPad will ask: Have you ever
smelled Play Doh?
component.
Question 5: the voice on the iPad says: Touch the picture of cinnamon.
the task).
If incorrect, the picture of cinnamon will flash and the voice will say: This is cinnamon.
The screen will change to the cinnamon picture and a voice on the iPad will ask: Have you ever
smelled cinnamon?
component.
Question 6: the voice on the iPad says: Touch the picture of coffee.
the task).
If incorrect, the picture of coffee will flash and the voice will say: This is coffee.
The screen will change and a voice on the iPad will ask: Have you ever smelled coffee?
component.
Question 7 the voice on the iPad says: Touch the picture of chocolate.
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the task).
If incorrect, the picture of chocolate will flash and the voice on the iPad will say: This is chocolate.
The screen will change to the chocolate picture and a voice on the iPad will ask: Have you ever
smelled chocolate?
component.
Question 8: the voice on the iPad says: Touch the picture of bubble gum.
the task).
If incorrect, the picture of bubble gum will flash and the voice will say: This is bubble gum.
The screen will change to the bubble gum picture and a voice on the iPad will ask: Have you ever
smelled bubble gum?
component.
At the end of these questions, the iPad screen will refresh and the voice on the iPad will ask the child to
touch those pictures that were not correctly identified on the first trial.
These requests will be made one by one until all the items are presented with the instruction: ‘Touch
the picture of….’ There are no corrections in this part, nor are there questions about whether the child
has smelled the item. Regardless of the child’s performance on the picture identification task, the iPad
will then move on to odor identification.
After this section, there is a button Touch and Hold Here to Continue at the bottom of the screen.
Touch and hold that button to continue.
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Part 2: Odor Identification:
Scratch ‘n’ Sniff Card Note: The odor on the card is strongest immediately after being scratched;
the examiner may need to remind the participant to smell the card as quickly as possible after
scratching it. If the child says he/she does not smell anything, the examiner should scratch the card
one more time and place it directly under the child’s nose, then ask the child to make his/her best
guess if he/she is not sure.
For this age group, the examiner will scratch the card and hand it to the participant, saying:
I am going to give you some stickers to smell. After you have smelled the sticker, touch the
picture that shows what you just smelled. If you want to change your choice, touch the hand,
also called the GO BACK button. Let’s begin.
If the child has difficulty touching the iPad screen, the examiner may register the participant’s choice by
touching the screen for him/her.
NOTE: The child is not permitted to go back beyond the last item he/she attempted; if the child
attempts to go back beyond the previous item, say: You can only go back to the last item you
smelled.
When the child has completed all five cards, say:
We are done with the smells.
The five odors presented are: Lemon, Play Doh, Bubble Gum, Chocolate, and Popcorn.
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C.5.2.2 NIH Toolbox Odor Identification Test Instructions Ages 10+
The task is introduced with the following Title Screen: NIH Toolbox Odor Identification Test 10+. At the
begin the test.
Instruction Screen:
The examiner says: This task involves smelling various odors, one at a time, and then trying to
identify them. The odors that you will smell are chosen from a variety of foods and objects that
people experience in everyday life. We are using scratch ‘n’ sniff cards to present the odors.
The examiner continues: Take the scratcher and scratch the card. Smell it right after you scratch
it, then look at the pictures on the screen. Touch the picture that best shows the odor you smelled
on the card. A new set of pictures will then appear on the screen and you will be asked to identify
the odor on the next card. If you want to change your last answer, touch the GO BACK button.
(NOTE: For the first item, the GO BACK button is deactivated as there is no item before this one).
Scratch ‘n’ Sniff Card Note: The odor on the card is strongest immediately after being scratched.
The examiner may need to remind the participant to smell the card as quickly as possible after
scratching it. If the participant says he/she does not smell anything, the examiner should scratch the
card one more time and place it directly under the participant’s nose, then ask the participant to make
his/her best guess if he/she is not sure.
The examiner should encourage the participant to smell the card more than once if needed.
If the participant has difficulty using the scratcher, the examiner may scratch the card and hand it to
the participant. Similarly, if the participant has difficulty touching the iPad screen, the examiner may
register the participant’s choice by touching the screen for him/her.
The examiner should repeat the sequence of handing the cards to the participant to scratch, smell, and
identify until all the cards have been used. For each trial, or as needed, repeat what was said above:
Take the scratcher and scratch this card; smell it, then look at the pictures on the screen. Touch
the picture that best shows the odor that you smelled on the card. If you want to change your last
answer, touch the GO BACK button.
NOTE: The participant is not permitted to go back beyond the last item he/she attempted. If the
participant attempts to go back beyond the previous item, say: You can only go back to the last
item you smelled.
When the participant has completed all nine cards, say: You have finished this activity.
The nine odors presented are: Lemon, Play Doh, Bubble Gum, Chocolate, Popcorn, Coffee, Smoke,
Natural Gas, and Flower.
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C.5.3 NIH Toolbox Visual Acuity Test
This activity is intended to measure visual acuity in adults and children.

Testing will use different sets of optotypes (letters) for children and adults. For the Visual Acuity Test,
the participant is seated 3 meters away from the iPad and the display should be at eye level.

• iPad
• Wireless keyboard (with extra AA batteries)
• Tablet stand
• Table
• Measuring tape
• Laminated HOTV letters for young children
• Go to the Settings app of the iPad and make sure Bluetooth is turned on.
• Make sure the keyboard is in discovery mode by pressing the round button at the top right end
of the keyboard and the small green light to the left of the button begins flashing.
• Select the Keyboard when it appears on the My Devices list on the iPad.
• When a pop up window appears on the iPad screen, follow the instructions and enter the
required code on the keyboard.
The usual keyboard on the iPad will not work when the external keyboard is working. To turn off
the external keyboard, press the round button at the top right end of the keyboard, move at least
15 meters from the iPad with the keyboard, or touch the “information” button  on the iPad and
touch “forget this device.”
Before testing begins:
• The examiner should move the iPad to a portable tablet stand that is placed on a table,
or use another method such that the iPad is 3 meters from the participant and at eye
level (this may also necessitate adjusting the participant’s chair height).
• It is recommended that the examiner have a printed copy of all instructions close at hand
before beginning this measure. This is particularly important for the training and practice
for the young children and may be important for older participants as well.
• Alternatively, for adults and older children, the examiner may hold the iPad and read the
initial instructional screens to the participant, after which the iPad should be placed on
the stand. If using this procedure, the examiner should try to stay close to the participant
while reading from the iPad (since explaining something from a distance of 3 meters
may seem unusual and very different from other measures where the participant and
examiner are sitting side by side), and then walk over to the stand (3 meters away) and
place the iPad on it before starting the items.
• Since the participant’s responses are recorded on the wireless keyboard, the wireless
keyboard must be paired by Bluetooth with the iPad.
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• The examiner should ascertain if the participant wears corrective lenses for distance,
and ensure he/she is wearing them. If the participant wears lenses but indicates he/she
has forgotten them (or does not have them for any reason), the examiner may choose to
continue testing or not; it is at the examiner’s discretion. However, if the participant
requires a very strong correction, testing without corrective lenses will not likely be valid.
The examiner should note any such irregularities and, if testing is completed, should
interpret results with caution.
iPad on stand
Visual Acuity set-up showing 3 meters distance
The examiner records the participant’s response on the wireless keyboard; specifically, once the
participant names (for young children, points on the HOTV sheet) the letter on the screen, the examiner
types that letter into the keyboard. After typing the letter, the examiner presses the spacebar to move on
to the next letter. The iPad software automatically scores the response and displays the next letter
accordingly.
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Age-Specific Instructions:
NIH Toolbox Visual Acuity Test Instructions Ages 3-7
NIH Toolbox Visual Acuity Test Instructions Ages 8+
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C.5.3.1 NIH Toolbox Visual Acuity Test Instructions Ages 3-7
Before beginning the testing, set up the iPad on a stand that sits on a table, such that the iPad is 3 meters
from the participant. Pair the wireless keyboard by Bluetooth with the iPad if it has not already been
paired.
The task is introduced with the Title Screen: NIH Toolbox Visual Acuity Test 3-7. At the bottom of the
screen is a button that instructs the examiner to Press the Spacebar to continue.
Because some children may not be able to name one or more of the letters HOTV, a laminated card is
also used with young participants, allowing them to point to what they saw on the screen without
verbalizing. The examiner should be seated next to the child so that he/she can see or hear what letter
the child chooses.
A brief training is included before the test, followed by a practice, to assure that the child knows what
needs to be done to complete the assessment. If the child does not succeed with the practice (as outlined
below), testing should be discontinued.
Training:
Once the child is seated in a chair that is 3 meters from the iPad, say: Now we are going to do an
activity that shows us how well you can see pictures on the iPad screen. Press Spacebar to
continue.
Hand the child the laminated card and say: Everything you will see is shown on this card. This is a
picture of an H, this is a picture of an O, this is a picture of a T, and this is a picture of a V (point
to each letter while naming). Now, you try to name the pictures.
Encourage the child to name the letters as best he/she can. If the child names all four letters correctly,
say: Good job.
If any are named incorrectly, point to each letter and say only one time as before: This is a picture of
an H, this is a picture of an O, this is a picture of a T, and this is a picture of a V. (Because letter
naming is not required to complete the test, it is OK if the child does not correctly name each letter.
Encourage the child’s efforts without providing negative feedback.) Then say: Let’s do some more.
Press Spacebar to continue.
Say: You are going to look on this screen (point to iPad); then, you will see a picture or letter (for
children who clearly know the alphabet, it is OK to say letter instead of ‘picture’). Each time, I want you
to tell me (or point on this card) what you saw on the screen. If you are not sure, it is OK to guess.
Are you ready to start? Press Spacebar to continue.
Practice:
The iPad will present one set of practice visual acuity trials (four letters) at a large size.
Rules:
1. If the child gets three or more correct, the program will continue automatically to visual acuity
testing.
2. If the child misses two or more of four, review the laminated pointing chart and ask him/her to
identify (either orally or by pointing) the four letters HOTV. If all are done correctly, see step c
below. If child cannot correctly identify the optotypes on the HOTV set, repeat the training above
one more time.
3. Proceed to a second practice trial set. If three or more of four are done correctly, proceed to live
visual acuity testing.
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4. If not, repeat (third practice trial set). If three or more are correct on the third practice trial, begin
visual acuity testing. If two or more are incorrect, stop the test, since this is the third practice trial
and the criterion of three or more of four correct is not achieved.
Visual Acuity Testing:

The examiner should say: You did great. Now, the letters will get smaller and smaller until you
cannot really see them. That is ok. We want to know how small they can get before you cannot
see them. Press Spacebar to continue.
Each time a letter is displayed, say: Tell me or point to what you see.
The examiner records the correctness of the participant’s response on the wireless keyboard; specifically,
once the participant names (for young children, points on the HOTV sheet) the letter on the screen, the
examiner types that letter into the keyboard. After typing the letter, the examiner presses the spacebar
to move on to the next letter.
The next item will not appear until the examiner has recorded the child’s response to the item currently
on screen. If the child is trying but struggling to verbalize the letters, remind him/her that pointing is OK,
saying: You can show me what you see.
The test will progressively present smaller letters if the child answers correctly or larger ones if the child
answers incorrectly, until an acuity score is established. The test will automatically end when the program
has calculated the acuity score.
Note: If a child’s Visual Acuity Test score is equivalent to 20/400 vision or worse, it suggests
serious uncorrected distance vision deficits exist. A follow-up evaluation by a vision professional
is suggested.
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C.5.3.2 NIH Toolbox Visual Acuity Test Instructions Ages 8+
Before beginning the testing, set up the iPad on a stand that sits on a table, such that the iPad is 3 meters
from the participant. Pair the wireless keyboard by Bluetooth with the iPad if it has not already been
paired.
The task is introduced with the Title Screen: NIH Toolbox Visual Acuity Test 8+. At the bottom of the
screen is a button that instructs the examiner to Press the Spacebar to continue.
Ask the participant if he/she wears glasses or contact lenses for distance vision. If the participant does
wear lenses but indicates he/she has forgotten them (or does not have them for any reason), the
examiner may choose to continue testing or not; it is at the examiner’s discretion. Moreover, if the
participant requires a very strong correction, testing will not likely be valid without the corrective lenses.
The examiner should note any such irregularities and, if testing is completed in such a case, the results
should be interpreted with caution.
Once the participant is seated in a chair that is 3 meters from the iPad, say: Now we are going to do an
activity where you will tell me what letters you see on the screen. You are going to look on this
screen (point to iPad) and you will see a letter. Each time, I want you to tell me the letter you saw
on the screen. If you are not sure, it is OK to guess. The letters will get smaller and smaller until
you cannot really see them. That is ok. We are trying to determine how small they can get before
you cannot see them. Are you ready to start? Press Spacebar on keyboard to continue.
Visual Acuity Test (with glasses or contact lenses if usually worn for distance vision): The examiner
should record the participant’s response on the keyboard by entering the letter said.
Each time a letter is displayed, say: Tell me what you see. At the examiner’s discretion, this can be
replaced by: Go ahead after a few letters have been displayed.
The examiner records the participant’s response on the wireless keyboard; specifically, once the
participant names the letter on the screen, the examiner types that letter into the keyboard. After typing
the letter, the examiner presses the spacebar to move on to the next letter. The iPad software will
automatically score the response and present the next item accordingly.
The next item will not appear until the examiner has recorded the participant’s response to the item
currently on screen. The test will progressively present smaller letters if the participant answers correctly
or larger ones if the participant answers incorrectly, until an acuity score is established. The test will
automatically end when the program has calculated the acuity score.
Note: If a participant’s Visual Acuity Test score is equivalent to 20/400 vision or worse, it suggests
serious uncorrected distance vision deficits exist. A follow-up evaluation by a vision professional
is suggested.
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C.5.4 NIH Toolbox Words-in-Noise Test
This measure quantifies a participant’s ability to hear words in a noisy environment.

XXVI. iPad
XXVII. Sennheiser HD201 headphones or similar
A female speaker instructs the participant to a say a one-syllable word while in the background, there is
the noise of multiple people speaking at the same time. At the beginning of the test, the speaker’s voice
is much louder than the background noise; as the test progresses, the speaker’s voice gradually
becomes softer and eventually is the same level as the background noise.
There are seven levels of word/noise ratios and five words at each level. Each ear is tested separately
and the test is concluded when a participant cannot repeat any of the five words at a given level in each
ear separately.
Each screen represents a different background noise level and on each, the examiner touches the
word(s) that the participant correctly identifies. If the participant correctly repeats at least one word at a
level, the audio files will continue to present words to that ear. If all five words at a given level are
incorrect, the iPad will begin testing the second ear.
For the second ear, a series of five words will appear on the iPad screen as before and the associated
audio files will play in the participant’s earphones. If all five words at a given level are incorrect for the
second ear, the examiner should touch the FINISH button.
If the participant repeats some words correctly from each of the seven levels, after all the levels have
been presented, the examiner should touch the FINISH button.
The computer will automatically score the participant’s performance.
If a participant wears hearing aids, they should be removed for the duration of this test.
Before a testing session, the examiner should confirm that the iPad volume is turned ON and set
to a mid-range level (i.e., a comfortable listening level).
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C.5.4.1 NIH Toolbox Words-in-Noise Test Instructions Ages 6+
The test begins with a Title Screen: NIH Toolbox Words-in-Noise Test 6+. At the bottom of the screen is
a button Touch and Hold Here to Continue. Touch and hold that button to begin the test.
Before placing the headphones on the participant’s head, the examiner should make sure that he/she
can see the participant’s face and hear his/her responses; at the same time, the participant should not
be able to read the iPad screen.
Since the headphones will block communication between the examiner and the participant, the
examiner should instruct the participant that if he/she does not hear anything in the headphones,
he/she should take them off and the examiner will try to rectify the situation (most likely by pressing the
button on the side of the iPad to increase the volume).
The examiner should introduce the task, reading the screen: You will hear a woman asking you to
repeat various words. Repeat the words she asks out loud so that I can hear you. For example, if
you hear her say, ‘Say the word dog,’ you would say, ‘dog.’ If you are not sure what she said, just
say what you think you heard. You will also hear people talking in the background. Do your best
to ignore them and to focus on the woman’s voice asking you to repeat the words. You will hear
words in only one ear and then in the other. Do you have any questions? Answer any questions
and say: Let’s begin.
The examiner should place the earphones on the participant’s head, making sure that the right
earphone is over the right ear and the left earphone is over the left ear.
Touch the button at the bottom of the screen that says Touch and Hold Here to Continue. This will
start the test.
First Ear:
A series of five words will appear on the iPad screen, along with the current dB level and the ear being
tested. The associated audio files will play in the participant’s earphones. The examiner should listen
carefully to the participant’s responses and touch any word that is said correctly. Incorrect words are
not marked.
Each screen represents a different background noise level and on each, the examiner touches the
word(s) that the participant correctly identifies. If the participant correctly repeats at least one word at a
level, the audio files will continue to present words to that ear. If all five words at a given level are
incorrect, the iPad will begin testing the second ear.
Second Ear:
As before, a series of five words will appear on the iPad screen, along with the current dB level and the
ear being tested. The associated audio files will play in the participant’s earphones. The examiner should
listen carefully to the participant’s responses and touch any word that is said correctly.
If the participant correctly repeats at least one word at a level, the audio files will continue to present
words to that ear. Incorrect words are not marked. If all five words at a given level are incorrect, the
iPad will stop playing the audio files, at which point the examiner should touch the FINISH button.
If the participant repeats some words correctly from each of the seven levels, after all the audio files are
presented, the examiner should touch the FINISH button.
The iPad will automatically score the participant’s performance.
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C.5.5 NIH Toolbox Regional Taste Intensity Test
This activity assesses a participant’s sensitivity to bitter and salty solutions in the mouth generally, as
well as specifically on the tip of the tongue. The participants should not have had drinks or food in the
30 minutes prior to the testing.
All the instructions are shown on the iPad. The participant’s responses are registered directly on the iPad
screen using a calibrated scale that ranges from No sensation to Strongest sensation of any kind.
Initially the participant is taught to use the scale and then is asked to rate the solutions as they are
presented in different areas of the mouth using the same scale.
This activity requires more preparation and uses more materials than other tests; the examiner
needs to have the following equipment nearby before beginning the test:
• iPad with stand (to minimize the possibility that liquid gets on the iPad)
• Laminated pictures of procedure
• Gloves (latex free)
• 2 sterile cotton swabs
• Bottle of purified water at room temperature
• Disposable cup for each participant
• Cup, basin, spittoon, or sink for spitting solutions and rinse water
• Quinine solution in small cups**
• Salt solution (NaCl) in small cups**
**The equipment needed and instructions for mixing the Salt and Quinine Solution are provided
in Appendix 7. In the past, these were produced by a third party; that party is no longer producing the
solutions. The solutions can be mixed by any user or third party having the appropriate equipment to do
so. Most pharmacies and some universities have the necessary equipment and supplies to produce the
solutions.
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C.5.5.1 NIH Toolbox Regional Taste Intensity Test Instructions Ages 12+
The task is introduced with the following Title Screen: NIH Toolbox Regional Taste Test 12+. At the
begin the test.
The iPad should be positioned so that both the examiner and the participant can see the screen, since
all instructions are on the screen and read together by both parties.
Say: Now I am going to test your sense of taste. To do this, we will be using a salty flavor and a
flavor found in tonic water. Touch and hold button at the bottom of the screen to move to next
screen.
Demonstration of the scale:
Say: Before the tasting, I am going to ask you to use this scale to rate how weak or strong some
sensations are to you. Some of these sensations are things that you will experience. Some of
these sensations are what you will recall experiencing in the past.
Continue: This scale ranges from ‘no sensation’ at the bottom to the ‘strongest sensation of any
kind’ at the top. The top of the scale (Strongest Sensation of Any Kind) refers to any kind of
experience, for example sound, brightness of light, even those sensations that might be painful.
Touch and hold button at the bottom of the screen to advance to the next screen.
Point to the scale on the screen and use one finger to indicate the bottom to the top, saying, This is
how you use this scale. Demonstrate how the participant can use his/her finger on the scale. Then
touch and hold button at the bottom of the screen to advance to the next screen.
Demonstration continued: Show the scale and say: You can use your finger to choose a word on the
scale that describes what you experience or what you remember. You can touch anywhere on the line.
For example, if the sensation you experience is more than ‘moderate’ but not quite ‘strong,’ you can use
your finger to touch a spot between moderate and strong. Demonstrate for the participant.
Then say: Move your finger until you think it best represents how you feel, and then remove your
finger. If you like, you can fine-tune your rating by using the up and down arrows to the right of
the scale. When you are happy with the position of the mark, touch the OK button.
205
Once the participant has touched the OK button, the practice screens appear preceded by a screen
that the examiner reads: Let’s try some examples. The scale on the screen will no longer have
instructions on it. The examiner should touch and hold button at the bottom of the screen to advance to
the next screen.
Practice Screen 1: Say: Use this scale to rate the brightness of a well-lit room. How strong or
intense is the brightness to you? When you are finished, touch the OK button.
Practice Screen 2: Say: Please remember the brightness of a dimly lit restaurant, where the only
light is from candles on the table. Would you say the intensity of a dimly lit restaurant is less
bright or brighter than the light in a well-lit room? Use the scale to rate the brightness of a dimly
lit restaurant. When you are finished, touch the OK button.
Practice Screen 3: Say: Now think about the brightest light you have ever seen. Use the scale to
rate the intensity or strength of the brightest light you have ever seen. When you are finished,
touch the OK button.
If a participant has difficulty touching the screen, he/she may point and the examiner may
touch. The examiner should say something like the following to the participant:
You can point to your choice and then I can touch the screen for you.
Test Items:
There are four trials: quinine on the tongue tip, salt on the tongue tip, quinine in the whole mouth,
and salt in the whole mouth. The examiner should follow the prescribed order.
Preparation for test items: Read: Now we are going to do the taste test. Before we begin, please
rinse out your mouth two times with the bottled water and then spit the rinse water into this
container (show container).
Continue: Now, I am going to ask you to rate the strength of these tastes. First, I will put some of
the solution across the tip of your tongue and ask for a rating. To begin, I will put on these
gloves. (See steps below).
Step 1: The examiner should put on gloves for the remainder of this measure.
Step 2: Say: Then, I will put this sterile cotton swab into the solution. Put the swabs into the cups
of solution.
The examiner should touch and hold button at the bottom of the screen to advance to next screen.
Step 2
Step 1 Step 3
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Test item 1:
Say: Now hold your tongue out. If the participant has difficulty doing this, show him/her the picture or
demonstrate. Say: I am going to start on your left side and gently put some solution across the tip
of your tongue.
The examiner should carefully and gently apply the solution in a slow, continuous motion from the left
side of the tongue across the tip and finishing on the right side of the tongue.
Move from left side to the middle to the right side.
Using the cotton swab, paint the quinine on the tip of the tongue as described earlier, and say: Now,
show me the strength or intensity of the taste on the scale you used before. Keep your tongue
out while you make the rating on the scale. Touch the OK button when you are finished. If you
should accidentally swallow any, it will not hurt you.
Transition screen 1:
Have the participant rinse out his/her mouth with the bottled water between Items 1 and 2 and read:
Please rinse out your mouth two times with the bottled water and spit the rinse water into this
container.
207
Test Item 2:
Read: Now hold your tongue out again. I am going to gently put some solution across the tip of
your tongue. Using the cotton swab, paint the salt solution (NaCl) on the tip of the tongue as described
earlier, and say: Now, show me the strength or intensity of the taste on the scale you used before.
Keep your tongue out while you make the rating on the scale. Touch the OK button when you are
finished. If you should accidentally swallow any, it will not hurt you.
Have the participant rinse out his/her mouth with the bottled water between Items 2 and 3 and read:
container.
Test Item 3:
Hand the participant a small cup with quinine and say: Next, I would like you to sip all the solution in
this cup. Try not to drink the solution, but hold it and gently move it around in your mouth until I
tell you to spit it out in this container. If you should accidentally swallow any, it will not hurt you.
After the participant sips the solution, the examiner should count for three seconds (one-thousand-one,
one-thousand-two, one-thousand-three), and then say: Spit out the solution in your mouth and
swallow whatever remains. Then, rate the strength or intensity of the taste on the same scale you
used before. Touch the OK button when you are finished.
Have the participant rinse out his/her mouth with the bottled water between Items 4 and 4 and say:
container.
Test Item 4:
Hand the participant a small cup with salt solution (NaCl) and say: Next, I would like you to sip
all the solution in this cup. Try not to drink the solution, but hold it and gently move it
around in your mouth until I tell you to spit it out in this container. If you should
accidentally swallow any, it will not hurt you.
After counting one-thousand-one, one-thousand-two, one-thousand-three once the participant has
sipped the solution, the examiner should say: Spit out the solution in your mouth and swallow
whatever remains. Then, rate the strength or intensity of the taste on the same scale you used
before. Touch the OK button when you are finished.
Final Screen:
After the last item is administered, give the participant the bottle of water and encourage him/her to
drink it and/or rinse some more. The examiner should say: Now that we have finished, you might
want to drink some more water to clean out your mouth.
The participant may be offered a candy to help overcome any remaining taste in his/her
mouth.
(Sugar-free candy may be needed for diabetic participants)
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209
Administering PROMIS
The Patient Reported Outcomes Measurement Information System (PROMIS) is a system of highly
reliable, precise measures of patient–reported health status for physical, mental, and social well-being.
PROMIS tools measure what patients are able to do and how they feel by asking questions. PROMIS
measures can be used as primary or secondary endpoints in clinical studies of the effectiveness of
treatment (see more at www.Healthmeasures.net/promis).
PROMIS Domains
PROMIS instruments measure outcomes by domains. A domain can be defined as the trait or
conceptual area that represents an instrument’s or item’s content (e.g., Fatigue).
PROMIS Instrument Formats

Each PROMIS instrument is administered in either a computerized adaptive testing (CAT), short form
(SF), Profile or Instruction format (see below). All currently included PROMIS instruments are self-
report (i.e., the respondent answers questions about him/herself).
Computer Adaptive Testing (CATs) – PROMIS CATs adapt to the examinee's trait level by selecting
items based on a respondent’s previous answers. CATs begin with a standard item (specific to that
measure). An algorithm is utilized to determine which item should be administered next. PROMIS
instruments, which use CAT as an administration method, are often referred to as “Banks.” CATS are
usually 4-6 items long.
Short Forms (SFs) – SFs are a more traditional instrument in that all items are administered in a set
(sequential) order.
Profiles – Profiles are similar to SFs, but they include sets of items from multiple domains. Therefore,
these instruments produce more than one IRT score, i.e., one score per domain. Profile instruments are
classified as Preset batteries, i.e., made up on individual short form instruments. See section 3 for a
more detailed description of Preset Batteries and a list of the short form instruments which make up the
PROMIS-29 Profile v2.0 preset battery.
The PROMIS-29 Profile v2.0 is the only PROMIS preset battery to be included in the App. It is made up
of 8 instruments. Each of the instruments in the battery is named for the short form, which together
comprise the Profile instrument. The short forms are also standalone instruments in the App. The short
form scoring procedure is used to score 7 of the instruments in the PROMIS-29 Profile v2.0 preset
battery. Scores appear per instrument in the data export.
Instructions - Instructions for PROMIS instruments are listed as an instrument. PROMIS Instructions
are optional and inclusion is at the discretion of users. It is recommended that if more than one
instrument is to be administered, these instructions should only be presented prior to the beginning of
the first instrument.
Time to administer
210
All individual PROMIS CAT and SF instruments take less than 5 minutes to complete. PROMIS Profile
instruments take less than 10 minutes to complete.
General Instructions
The participant answers PROMIS instruments at his/her own speed. An examiner need not be present.
After a question is answered, the screen advances automatically to the next question.
D.1 PROMIS Instruments List
Instrument Name
211
PROMIS Ped CAT v2.0 - Fatigue PROMIS CAT v1.2 - Physical Function
PROMIS Ped SF v2.0 - Fatigue 10a PROMIS CAT v1.2 - Upper Extremity
PROMIS SF v1.0 - Phys Func Samples w Mobility

PROMIS Parent Proxy CAT v2.0 - Fatigue
Aid
PROMIS Parent Proxy SF v2.0 - Fatigue 10a PROMIS SF v1.0 - Phys. Function 10a
PROMIS SF v1.1 - Global Health PROMIS SF v1.0 - Phys. Function 20a
PROMIS CAT v1.1 - Pain Interference PROMIS SF v1.0-Physical Function 4a
PROMIS SF v1.0 - Pain Interference 6a PROMIS SF v1.2 - Physical Function 6b
PROMIS SF v1.0 - Pain Interference 6b PROMIS SF v1.2 - Physical Function 8b
PROMIS SF v1.0 - Pain Interference 8a PROMIS Ped CAT v2.0 - Mobility
PROMIS SF v1.0-Pain Interference 4a PROMIS Ped CAT v2.0 - UpperExtremity
PROMIS Ped CAT v2.0 - Pain Interference PROMIS Ped SF v2.0 - Mobility 8a
PROMIS Ped SF v2.0 - Pain Interference 8a PROMIS Ped SF v2.0 - Upper Extremity 8a
PROMIS Parent Proxy CAT v2.0 - Pain

PROMIS Parent Proxy CAT v2.0 - Mobility
Interference
PROMIS Parent Proxy SF v2.0 - Pain Interfere 8a PROMIS Parent Proxy CAT v2.0 - Upper Extremity
PROMIS Scale v1.0 - Pain Intensity 3a PROMIS Parent Proxy SF v2.0 - Mobility 8a
PROMIS CAT v1.0 - Phys Func Samples w PROMIS Parent Proxy SF v2.0 - Upper Extremity
Mobility Aid 8a
2
Instrument Name
PROMIS SF v1.0 - Psychosoc Illness Impact-Neg
PROMIS SF v2.0 - Social Isolation 8a
4a
PROMIS SF v1.0 - Psychosoc Illness Impact-Neg
PROMIS Ped CAT v2.0 - Peer Relationships
8a
PROMIS SF v1.0 - Psychosoc Illness Impact-Pos
PROMIS Ped SF v2.0 - Peer Relationships 8a
4a
PROMIS CAT v2.0 - Emotional Support PROMIS Parent Proxy CAT v2.0 - Peer Relations
PROMIS CAT v2.0 - Informational Support PROMIS Parent Proxy SF v2.0 - Peer Relations 7a
PROMIS CAT v2.0 - Instrumental Support PROMIS CAT v2.0 - Satisfaction Roles Activities
PROMIS CAT v2.0 - Social Isolation PROMIS SF v1.0 - Social Sat Role 4a
PROMIS SF v2.0 - Companionship 4a PROMIS SF v2.0 - Satisfaction Roles Activities 4a
PROMIS SF v2.0 - Companionship 6a PROMIS SF v2.0 - Satisfaction Roles Activities 8a
PROMIS CAT v1.0 - Self-Efficacy Manage

PROMIS SF v2.0 - Emotional Support 4a
Emotions
PROMIS SF v2.0 - Emotional Support 8a PROMIS CAT v1.0 - Self-Efficacy Manage Meds/Tx
PROMIS SF v2.0 - Informational Support 4a PROMIS CAT v1.0 - Self-Efficacy Manage Soc Inter
PROMIS CAT v1.0 - Self-Efficacy Manage

PROMIS SF v2.0 - Informational Support 8a
Symptoms
PROMIS SF v1.0 - Self-Efficacy Manage Day Activ
PROMIS SF v2.0 - Instrumental Support 4a
4a
PROMIS SF v1.0 - Self-Efficacy Manage Emotions
4a
PROMIS SF v1.0 - Self-Efficacy Manage Meds/Tx

4a
PROMIS SF v1.0 - Self-Efficacy Manage Soc Inter

4a
PROMIS SF v1.0 - Self-Efficacy Manage Symptoms
4a
2
Instrument Name
PROMIS Bank v1.0 - Vaginal Discomfort PROMIS CAT v1.0 - Sleep Disturbance
PROMIS CAT v1.0 - Erectile Function PROMIS CAT v1.0 - Sleep-Related Impairment
PROMIS Bank v1.0 - Global Satisfaction w Sex

PROMIS SF v1.0 - Sleep Disturb 8b
Life
PROMIS Bank v1.0 - Interest in Sexual Activity PROMIS SF v1.0 - Sleep Disturbance 8a
PROMIS Bank v1.0 - Lubrication PROMIS SF v1.0 - Sleep-Related Impairment 8a
PROMIS Pool v1.0 - Orgasm PROMIS SF v1.0-Sleep Disturbance 4a
Neuro-QoL
Neuro-QoL (Quality of Life in Neurological Disorders) is a measurement system that evaluates
and monitors the physical, mental, and social effects experienced by adults and children living
with neurological conditions.
Adult Assessment
Neuro-QoL developed a set of health-related quality of life measures for use with adults who
have a neurological condition or disorder. The self-report measures can be completed by a
proxy responder when necessary.
3
Pediatric Assessment
Neuro-QoL developed a set of health-related quality of life measures for use with 8-17 year olds
who have a neurological condition or disorder. The self-report measures can be completed by a
parent or caregiver when necessary.
Neuro-QoL is Appropriate for Use Across a Range of Neurological

Conditions
4
Neuro-QoL measures can be used in a range of adult and pediatric neurological conditions
including but not limited to: stroke, multiple sclerosis, Parkinson’s disease, epilepsy,
amyotrophic lateral sclerosis (ALS), traumatic brain injury (TBI), military deployment–related
traumatic brain injury (MDR-TBI), spinal cord injury (SCI), and Huntington’s disease (HD).
Neuro-QoL measures can be administered alongside PROMIS® or NIH Toolbox® measures
that assess other aspects of health and function.
To learn more you can watch a video located here:
https://www.youtube.com/watch?v=LTkDP6yZ18o
E.1 Neuro-QoL Instrument List
List of Adult Measures

Neuro-QoL Item Bank v1.0 - Ability to Participate in Social Roles and Activities
Neuro-QoL Item Bank v1.0 - Anxiety
Neuro-QoL Item Bank v1.0 - Depression
Neuro-QoL Item Bank v1.0 - Emotional and Behavioral Dyscontrol
Neuro-QoL Item Bank v1.0 - Fatigue
Neuro-QoL Item Bank v1.0 - Lower Extremity Function - Mobility
Neuro-QoL Item Bank v1.0 - Positive Affect and Well-Being
Neuro-QoL Item Bank v1.0 - Stigma
Neuro-QoL Item Bank v1.0 - Upper Extremity Function - Fine Motor, ADL
Neuro-QoL Item Bank v1.1 - Satisfaction with Social Roles and Activities
Neuro-QoL Item Bank v2.0 - Cognitive Function
Neuro-QoL Scale v1.0 – Communication
Neuro-QoL Short Form v1.0 - Ability to Participate in Social Roles and Activities
Neuro-QoL Short Form v1.0 - Anxiety
Neuro-QoL Short Form v1.0 - Depression
Neuro-QoL Short Form v1.0 - Emotional and Behavioral Dyscontrol
Neuro-QoL Short Form v1.0 - Fatigue
Neuro-QoL Short Form v1.0 - Lower Extremity Function – Mobility
Neuro-QoL Short Form v1.0 - Positive Affect and Well-Being
Neuro-QoL Short Form v1.0 - Sleep Disturbance
Neuro-QoL Short Form v1.0 - Stigma
Neuro-QoL Short Form v1.0 - Upper Extremity Function - Fine Motor, ADL
Neuro-QoL Short Form v1.1 - Satisfaction with Social Roles and Activities
Neuro-QoL Short Form v2.0 - Cognitive Function
5
List of Pediatric Measures
Neuro-QoL Item Bank v1.0 - Pediatric Anxiety
Neuro-QoL Item Bank v1.0 - Pediatric Social Relationships - Interaction with
Peers
Neuro-QoL Item Bank v1.0 - Pediatric Stigma
Neuro-QoL Item Bank v1.1 - Pediatric Depression
Neuro-QoL Item Bank v2.0 - Pediatric Cognitive Function
Neuro-QoL Item Bank v2.1 - Pediatric Fatigue
Neuro-QoL Scale v1.1 - Pediatric Lower Extremity Function - Mobility
Neuro-QoL Scale v1.1 - Pediatric Upper Extremity - Fine Motor, ADL

Neuro-QoL Short Form v1.0 - Pediatric Anger
Neuro-QoL Short Form v1.0 - Pediatric Anxiety
Neuro-QoL Short Form v1.0 - Pediatric Depression
Neuro-QoL Short Form v1.0 - Pediatric Pain
Neuro-QoL Short Form v1.0 - Pediatric Social Relationships - Interaction with
Peers
Neuro-QoL Short Form v1.0 - Pediatric Stigma
Neuro-QoL Short Form v2.0 - Pediatric Cognitive Function
Neuro-QoL Short Form v2.1 - Pediatric Fatigue
TBI-QOL
Traumatic Brain Injury – Quality of Life Measurement System:
The Traumatic Brain Injury – Quality of Life (TBI-QOL) measurement system is a patient
reported outcome measurement system that assesses 23 areas of physical, cognitive,
emotional, and social functioning specific to persons who have sustained a traumatic brain
injury. The TBI-QOL measurement system can be used for clinical care and research in
traumatic brain injury (TBI) rehabilitation. Some scales are unique to the needs of individuals
with TBI (e.g., headache pain) while other scales are linked to PROMIS and Neuro-QoL items
recalibrated to optimize assessment within the TBI population (e.g., pain interference,
depression, anxiety).
TBI-QOL Instrument Formats

The TBI-QOL is available in two basic formats: a computer adaptive test (CATs) and/or fixed
length short-form version (SF). Item banks have been calibrated using item response theory
(IRT) and are available as either CATs or SFs. Scales have also been calibrated using IRT but
are only available as fixed-length forms.
The TBI-QOL measurement system was developed with funding from the National
Institutes of Health (National Institute of Child Health and Human Development /National Center
6
for Medical Rehabilitation Research and the National institute of Neurological Disorders and
Stroke) and the National Institute on Disability and Rehabilitation Research.
TBI-QOL Overlap with PROMIS and Neuro-QoL

Overlap with PROMIS and Neuro-QoL: When there is a TBI-QOL item bank in an area
that is also assessed by PROMIS or Neuro-QoL, the TBI-QOL item bank should be used as it
has been optimized for a TBI population. For these “optimized” PROMIS/Neuro-QoL item banks,
scores have been transformed back to the Neuro-QoL or PROMIS metric so that scores
reference the original population (i.e., general population or mixed general + neurological
population). The TBI-QOL also includes new, TBI-specific item banks that are not part of the
Neuro-QoL or PROMIS systems. These are:
Communication/Comprehension Independence
Grief/Loss Resilience
Headache Pain Self-Esteem
These new item banks reference the TBI population. In other words, the mean of 50 on
the Headache Pain bank is relative to a sample of individuals with TBI.
Item banks that produce a redundant score with PROMIS (but are optimized for TBI) are as
follows:
Anger Fatigue
Anxiety Pain Interference
Depression
Item banks that produce a redundant score with Neuro-QoL (but are optimized for TBI) are as
follows:
Ability to Participate in Social Roles/Activities Positive Affect & Well-Being
Cognition – General Concerns Satisfaction w/Social Roles/Activities
Cognition – Executive Function Stigma
Emotional & Behavioral Dyscontrol Upper Extremity Function
Mobility
The TBI-QOL was developed with and for adults ages 18 and over who have sustained
a traumatic brain injury (TBI). The measures may be completed in interview format (either in
person or over the phone) or by independent self-report. Each instrument takes approximately
2-3 minutes to complete.
F.1 TBI-QOL Instrument List
List of TBI-QOL Measures
7
TBI-QOL Bank v1.0 - Ability to Participate in SRA
TBI-QOL Bank v1.0 - Anger
TBI-QOL Bank v1.0 - Anxiety
TBI-QOL Bank v1.0 - Communication
TBI-QOL Bank v1.0 - Depression
TBI-QOL Bank v1.0 - Emotional & Behavioral Dyscontrol
TBI-QOL Bank v1.0 - Executive Function
TBI-QOL Bank v1.0 - Fatigue
TBI-QOL Bank v1.0 - General Concerns
TBI-QOL Bank v1.0 - Grief - Loss
TBI-QOL Bank v1.0 - Headache
TBI-QOL Bank v1.0 - Independence
TBI-QOL Bank v1.0 - Mobility
TBI-QOL Bank v1.0 - Pain Interference
TBI-QOL Bank v1.0 - Positive Affect and Well-Being
TBI-QOL Bank v1.0 - Resilience
TBI-QOL Bank v1.0 - Satisfaction with SRA
TBI-QOL Bank v1.0 - Self-Esteem
TBI-QOL Bank v1.0 - Stigma
TBI-QOL Bank v1.0 - Upper Extremity/ADL
TBI-QOL Scale v1.0 - Asking For Help
TBI-QOL SF v1.0 - Ability to Part. In SRA SF10a
TBI-QOL SF v1.0 - Anger SF10a
TBI-QOL SF v1.0 - Anxiety SF10a
TBI-QOL SF v1.0 - Cognition - General Concerns SF10a
TBI-QOL SF v1.0 - Communication SF9a
TBI-QOL SF v1.0 - Depression SF10a
TBI-QOL SF v1.0 - Emotional & Behavioral Dyscontrol SF10a
TBI-QOL SF v1.0 - Executive Function SF10a
TBI-QOL SF v1.0 - Fatigue SF10a
TBI-QOL SF v1.0 - Grief - Loss SF9a
TBI-QOL SF v1.0 - Headache SF10a
TBI-QOL SF v1.0 - Independence SF8a
TBI-QOL SF v1.0 - Mobility SF9a
TBI-QOL SF v1.0 - Pain Interference SF10a
TBI-QOL SF v1.0 - Pos. Affect and Well-Being SF9a
TBI-QOL SF v1.0 - Resilience SF10a
TBI-QOL SF v1.0 - Satisfaction with SRA SF10a
TBI-QOL SF v1.0 - Self-Esteem SF10a
8
TBI-QOL SF v1.0 - Stigma SF7a
TBI-QOL SF v1.0 - Upper Extremity/ADL SF9a
SCI-QOL
Spinal Cord Injury – Quality of Life Measurement System:
The Spinal Cord Injury – Quality of Life (SCI-QOL) measurement system is a patient
reported outcomes measurement system that assesses 22 areas of physical, emotional, and
social functioning specific to persons who have sustained a spinal cord injury. The SCI-QOL
measurement system was developed using the PROMIS standards of development and can be
used for clinical care and research in spinal cord injury (SCI) rehabilitation. Some scales are
unique to the needs of individuals with SCI (e.g., bladder management difficulties, grief and
loss, independence) while other scales are linked to PROMIS and Neuro-QoL but items have
been recalibrated to optimize assessment within the SCI population (e.g., pain interference,
depression, anxiety).
SCI-QOL Instrument Formats

SCI-QOL instruments are available in two basic formats: as a computer adaptive test
(CAT) and/or fixed length short-form version (SF). Item banks have been calibrated using item
response theory (IRT) and are available as either CATs or SFs. Scales have also been
calibrated using IRT but are only available as fixed-length forms.
The SCI-QOL measurement system was developed with funding from the National
Institutes of Health (National Institute of Child Health and Human Development /National Center
for Medical Rehabilitation Research and the National institute of Neurological Disorders and
Stroke) and the National Institute on Disability and Rehabilitation Research.
SCI-QOL Overlap with PROMIS and Neuro-QoL

When there is a SCI-QOL item bank in an area that is also assessed by PROMIS or Neuro-QoL,
the SCI-QOL item bank should be used as it has been optimized for a SCI population. For these
“optimized” PROMIS/Neuro-QoL item banks, scores have been transformed back to the Neuro-
QoL or PROMIS metric so that scores reference the original population (i.e., general population
or mixed general + neurological population).
Item banks that produce a redundant score with PROMIS (but are optimized for SCI) are as
follows:
Anxiety Pain Behavior (Scale)
Depression Pain Interference
Item banks that produce a redundant score with Neuro-QOL (but are optimized for SCI) are as
follows:
Ability to Participate in Social Roles/Activities
Positive Affect & Well-being
Stigma
Satisfaction with Social Roles/Activities
9
The SCI-QOL also includes new, SCI-specific item banks/scales that are not part of the Neuro-
QoL or PROMIS systems. These are:
Ambulation (SCI-FI v1.0) Independence
Basic Mobility (SCI-FI v1.0) Pressure Ulcers
Bladder Complications Scale Psychological Trauma
Bladder Management Difficulties Resilience
Bowel Management Difficulties Self Care (SCI-FI v1.0)
Fine Motor Function (SCI-FI v1.0) Self Esteem
Grief/Loss Wheelchair Mobility (SCI-FI v1.0)
These new item banks reference the SCI population. In other words, the mean of 50 on the
Bladder Management Difficulties item bank is relative to a sample of individuals with SCI.
General Instructions: The SCI-QOL was developed with and for adults ages 18 and over with
spinal cord injury (SCI). The measures may be completed in interview format (either in person
or over the phone) or by independent self-report. Each instrument takes approximately 2-3
minutes to complete.
G.1 SCI-QOL Instrument List
List of SCI-QOL Measures

SCI-QOL Bank v1.0 - Ability to Participate in SRA
SCI-QOL Bank v1.0 - Anxiety
SCI-QOL Bank v1.0 - Bladder Mgmt. Difficulties
SCI-QOL Bank v1.0 - Bowel Mgmt. Difficulties
SCI-QOL Bank v1.0 - Depression
SCI-QOL Bank v1.0 - Grief-Loss
SCI-QOL Bank v1.0 - Independence
SCI-QOL Bank v1.0 - Pain Interference
SCI-QOL Bank v1.0 - Positive Affect and Well-Being
SCI-QOL Bank v1.0 - Resilience
SCI-QOL Bank v1.0 - Satisfaction with SRA
SCI-QOL Bank v1.0 - Self-Esteem
SCI-QOL Bank v1.0 - Stigma
SCI-QOL Bank v1.0 - Trauma
SCI-QOL Scale v1.0 - Bladder Complications
SCI-QOL Scale v1.0 - Pain Behavior
SCI-QOL Scale v1.0 - Pressure Ulcers
SCI-QOL SF v1.0 - Ability to Part. In SRA SF10a
SCI-QOL SF v1.0 - Anxiety SF9a
10
SCI-QOL SF v1.0 - Bladder Mgmt. Difficulties SF8a
SCI-QOL SF v1.0 - Bowel Mgmt. Difficulties SF9a
SCI-QOL SF v1.0 - Depression SF10a
SCI-QOL SF v1.0 - Grief-Loss SF9a
SCI-QOL SF v1.0 - Independence SF8a
SCI-QOL SF v1.0 - Pain Interference SF10a
SCI-QOL SF v1.0 - Pos. Affect and Well-Being SF10a
SCI-QOL SF v1.0 - Resilience SF8a
SCI-QOL SF v1.0 - Satisfaction with SRA SF10a
SCI-QOL SF v1.0 - Self-Esteem SF8a
SCI-QOL SF v1.0 - Stigma SF10a
SCI-QOL SF v1.0 - Trauma SF8a
SCI-FI
Spinal Cord Injury – Functional Index
The Spinal Cord Injury – Functional Index (SCI-FI) version 1.0 is the Physical Function
domain of the larger SCI-QOL measurement system and is comprised of 5 item response theory
(IRT)-calibrated item banks: Basic Mobility, Self Care, Fine Motor Functioning, Wheelchair
Mobility, and Ambulation. The SCI-FI has incorporated items from the PROMIS and Neuro-QoL
measurement systems verbatim that have been optimized for SCI and supplemented by several
items targeted to this specific population. Instructions direct participants to respond to items with
the amount of difficulty they have performing various tasks without the use of special equipment
or help from another person and as such these measures are intended to capture underlying
physical capacity in each area. The exception is Wheelchair Mobility which asks questions
about how they are able to move with the assistance of a wheelchair.
The SCI-FI v1.0 item banks can be used for clinical care and research in spinal cord
injury (SCI) rehabilitation. The SCI-FI v1.0 is available in two basic formats: computer adaptive
test (CAT) and/or fixed length short-form version (SF). Since the NIH Toolbox iPad app does not
support CATs with skip patterns, the NIH Toolbox iPad app contains the abbreviated SCI-FI
v1.0 CORE ITEMS CATs. These are CATs in which certain items (i.e., those that are only
appropriate for a subset of participants and thus require skip logic to administer) have been
omitted from the banks. The scores on the CORE ITEMS CATs are very highly correlated with
scores on CATs which draw from the full item banks.
The SCI-FI v1.0 measurement system was developed with funding from the US
Department of Education and the National Institute on Disability and Rehabilitation Research.
General Instructions: The SCI-FI item banks were developed with and for adults ages 18 and
over who have sustained a spinal cord injury (SCI). The measures may be completed in
interview format (either in person or over the phone) or by independent self-report. Each
instrument takes approximately 2-3 minutes to complete.
11
List of SCI-FI Measures
SCI-FI v1.0 Ambulation - Core Items CAT
SCI-FI v1.0 Basic Mobility - Core Items CAT
SCI-FI v1.0 Basic Mobility SF 11a
SCI-FI v1.0 Fine Motor Function - Core Items CAT
SCI-FI v1.0 Fine Motor SF 10b - Tetra
SCI-FI v1.0 Fine Motor SF 11b - Para
SCI-FI v1.0 Fine Motor SF 9a
SCI-FI v1.0 Power Wheelchair SF 10b - Para
SCI-FI v1.0 Power Wheelchair SF 10b - Tetra
SCI-FI v1.0 Self Care - Core Items CAT
SCI-FI v1.0 Self Care SF 10b - Para
SCI-FI v1.0 Self Care SF 11a
SCI-FI v1.0 Self Care SF 11b - Tetra
SCI-FI v1.0 Wheelchair Mobility Manual Wheelchair Core Items CAT
SCI-FI v1.0 Wheelchair Mobility Power Wheelchair Core Items CAT
12
Appendix 1 – NIH Toolbox App Terms and Conditions
The NIH Toolbox Terms and Conditions contained in this document (hereinafter referred to as
“NTAC”) serve as an agreement between Northwestern University (NU) and the National
Institutes of Health (NIH), hereinafter referred to as “NU/NIH,” and users of any and all aspects
or components of the NIH Toolbox, hereinafter referred to as “You” or “User.”
Use of the NIH Toolbox measures/instruments, related materials, and services require
acceptance of all terms and conditions stated herein. You agree to abide by all of NTAC as a
condition of reviewing or using the NIH Toolbox. No modifications or additions to these terms
and conditions are binding upon NU/NIH unless previously agreed to in writing by an authorized
representative of NU or the NIH. NU/ NIH reserves the right to update the NTAC at any time.
Changes in the NTAC shall apply to new users, new measures and to new projects created by
existing users after such changes are posted.
COPYRIGHT NOTICE
NIH Toolbox tests, test protocols, test items, norms, norms tables, scoring programs, scoring
keys (including scoring algorithms, scale definitions, scale membership, and scoring directions),
score reports, software, and other NIH Toolbox-related materials are ©2016 Northwestern
University and the National Institutes of Health. Information and materials contributed to the NIH
Toolbox by other individuals/entities are being used with the permission of the copyright holders.
Toolbox materials are not to be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from NU/NIH. The reproduction of any part of
NU/NIH's copyrighted tests and related materials in any way, whether the reproductions are sold
or furnished free for use, is a violation of federal copyright law. No adaptations, translations,
modifications, or special versions may be made without permission in writing from NU/NIH;
moreover, users are advised that such adaptations, translations, modifications, or special
versions may affect the validity of the tests even if permission is granted.
PERSONAL AND NON-COMMERCIAL USE LIMITATION

Any publication or presentation of results obtained from studies conducted using NIH
Toolbox measures should include a statement that NIH Toolbox version 2.0
measures/instruments were used, and reference the NIH Toolbox website (
www.Healthmeasures.net/nih-toolbox) for further information.
TERMS AND CONDITIONS OF USE
CONFIDENTIALITY. User acknowledges and agrees that the contents of the NIH
Toolbox may constitute trade secrets, which include confidential and proprietary
material, information, and procedures. User will not resell or otherwise distribute
materials, or authorize or allow disclosure of the contents of a test instrument protocol,
including test questions and answers, or normative data, except under the limited
circumstances described in the section titled, "Maintenance of Test Security and Test
13
Use," or as otherwise contemplated in the published manual associated with the test.
User acknowledges and agrees that the use or disclosure of trade secrets in a manner
inconsistent with the provisions of this Agreement may cause NU/NIH irreparable
damage, for which remedies other than injunctive relief may be inadequate.
Accordingly, User agrees that in any request by NU/NIH to a court of competent
jurisdiction for injunctive or other equitable relief seeking to restrain such use or
disclosure, User will not maintain that such remedy is not appropriate under the
circumstances.
PERMISSIONS AND LICENSING POLICY

Reproduction of any NIH Toolbox materials requires the prior written consent of NU/NIH.
Questions and answers, including practice questions and answers, may not be reproduced
without written permission, regardless of the number of lines or items involved. Test copies may
not be bound in theses or reports placed in libraries, generally circulated, or accessible to the
public, or in any article or text of any kind.
NU/NIH will consider requests for permission to reproduce, modify, or translate part or all of any
copyrighted publication and will consider the granting of licenses for use of NU/NIH copyrighted
materials. Requests to reproduce, translate, adapt, modify, or make special versions of these
publications should be made by written request through the (Please enter request details in the
message box.) Once approved, any reproduction must include acknowledgement of the source,
test, publisher, and copyright notice.
All requests to reproduce, translate, adapt, modify or make special versions of should be sent to
help@healthmeasures.net
PERMISSION TO USE COPYRIGHTED TEST NORMS

NU/NIH have the sole right to authorize reproductions of any portion of their published tests,
including test norms. Copying of test norms without authorization is a violation of federal
copyright law. The term "copying" includes, but is not limited to, entry of test NIH Toolbox
norms into a computer's memory for purposes of test processing, scoring, or reporting. Any
person or organization wanting to use NU/NIH test norms must submit a If permission is
granted, a fee may be charged. Permission from NU/NIH for use of test norms does not imply
endorsement of, or responsibility for, the accuracy or adequacy of any test processing, scoring,
or reporting service.
MODIFICATION OF NIH TOOLBOX COMPONENTS

NU/NIH recognizes the importance of continued scientific development of the NIH Toolbox
measures to meet the needs of researchers, but emphasizes the importance of maintaining
rigorous measurement standards. Therefore, User may make modifications to NIH Toolbox
tests and test items if, and only if, the following conditions are met:
1. Specific modification plans must be enumerated and submitted in writing to NU/NIH
for approval. This request must include the specific changes to be made and the
rationale for the changes. This written request must be signed by the lead researcher.
14
2. User may not make modifications to any component of NIH Toolbox without written
consent of NU/NIH.
3. All modifications should be fully validated against the existing NIH Toolbox
measure(s) on which they were based. Plans for a concurrent validation study must be
included in the written request for modifications. If no validation study is planned, this
must be noted in the written request, along with an explanation.
4. User must send validation study results to NU/NIH for review prior to publication citing
any results of said study or any results citing use of NIH Toolbox.
5. NU/NIH will review validation study data and will inform User if modification to NIH
Toolbox measure(s) constitute an “Approved Adaptation” or a “Non-Validated
Adaptation” of NIH Toolbox. NU/NIH will update www.Healthmeasures.net/nih-toolbox
accordingly to inform other users and prospective users of these modifications, along
with contact information for the lead researcher.
6. User must cite NIH Toolbox in any and all presentations, publications, or other third-
party sharing of research data, indicating whether any measures used constitute
Approved Adaptations or Non-Validated Adaptations. The citation must include the
following statement: “All NIH Toolbox-related materials are ©2016 Northwestern
University and the National Institutes of Health.”
7. NU/NIH maintains all rights to all translations, Approved Adaptations as well as Non-
Validated Adaptations of NIH Toolbox tests and test items made by User. User may
under no circumstances license, distribute, or share any components of NIH Toolbox
with third parties, regardless of the extent of modifications, without official, written
consent of NU/NIH. User is entitled to no ownership claim of intellectual property as a
result of making any NIH Toolbox modifications, and is hereby enjoined from
communicating or stating any such claims.
All requests of modification to the NIH Toolbox instruments should be sent to
help@healthmeasures.net
MAINTENANCE OF TEST SECURITY AND TEST USE

Each person or institution using the NIH Toolbox must agree to comply with these basic
principles of test security:
• Test takers must not receive test answers before beginning the test.
• Test questions are not to be reproduced or paraphrased in any way.
• Access to test materials must be limited to qualified persons with a responsible,
professional interest who agree to safeguard their use.
• Test materials and scores may be released only to persons qualified to interpret and use
them properly.
If a test taker or the parent of a child who has taken a test wishes to examine test responses or
results, the parent or test taker may be permitted to review the test and the test answers in the
15
presence of a representative of the school, college, or institution that administered the test.
Such review should not be permitted in those jurisdictions where applicable laws require the
institution to provide a photocopy of the test subsequent to review. If you are not certain of the
effect of the laws in jurisdiction, please contact your jurisdiction's professional organization.
USER QUALIFICATIONS
Cognition test users must have the appropriate knowledge, skills, training and experience to
responsibly use NIH Toolbox measures. “Test users” are those persons responsible for the
selection, administration, scoring and interpretation of tests and the communication of results.
Therefore, NU/NIH reserves the right to ask individuals requesting access to NIH Toolbox
measures to provide documentation that they have the experience and training necessary to
use those measures, or are working under the supervision of someone qualified to use those
measures. In particular, User may be asked to provide documentation of qualifications for
measures classified as “C-Level.” C-Level tests require a high degree of expertise in test
interpretation, and thus can only be requested by a User with state licensure or certification to
practice in a field related to the request, or a doctorate degree in psychology, education, or a
closely related field, with formal training in the ethical administration, scoring, and interpretation
of clinical assessments related to the intended use of the assessment. Any users of C-Level
assessments must be supervised by one or more users with C-Level qualifications, which must
have been provided in advance to NU/NIH per this process.
RULES GOVERNING USE OF THE NIH TOOLBOX BY VARIOUS CATEGORIES OF USERS

Universities, schools, organizations, businesses, clinics, and hospitals are subject to the
guidelines set forth above and must have appropriately qualified individuals on staff in order to
use the NIH Toolbox cognition tests. These individuals must complete a Registration Form and
provide information as to their qualifications.
PROTECTIVE ORDERS. User agrees to seek a protective order safeguarding the
confidentiality of test materials classified by NU/NIH as “C-level” assessments if User is required
to produce such materials in court or administrative proceedings.
NO WARRANTY. NU/NIH make no warranties, expressed or implied, including warranties of
merchantability or fitness for a particular purpose. NU/NIH will not, under any circumstances, be
liable for User's expense for delays, for costs of substitute materials, or for possible lost income,
grants, profits, or any other special or consequential damages that may result from using the
NIH Toolbox.
LIMITATION OF LIABILITY. In no event will NU/NIH be liable for damages arising under this
agreement, or otherwise arising from the order(s) contemplated under this agreement.
NOTICES. Any required notices shall be given in writing to User at the most recent contact
information provided by User to NU/NIH. NU/NIH may send You notice by electronic mail as an
alternative to conventional mail.
©2016 Northwestern University and the National Institutes of Health
PROMIS TERMS AND CONDITIONS
7/6/2015
16
You understand and agree that the PROMIS Health Organization and PROMIS Cooperative
Group provide access to PROMIS instruments (e.g., item banks, short forms, profile measures)
subject to the PROMIS Terms and Conditions (PTAC). The PROMIS Health
Organization/Cooperative Group reserves the right to update the PTAC at any time. Changes in
the PTAC will apply to new users, new instruments and to new projects created by existing
users after these changes are posted. The most current version of the PTAC can be reviewed
by clicking on the Terms of Use hypertext link located in Assessment Center or on the
Assessment Center Homepage (www.assessmentcenter.net).
TERMS FOR USE OF PROMIS INSTRUMENTS
PROMIS instruments measuring a variety of domains (see nihpromis.org for full domain
framework) are available for adult and pediatric self-report and parent proxy report. These tools
were developed in the English language using extensive qualitative methods to ensure
conceptual and semantic clarity. They have been tested for reliability and comparability to more
established measures of these same content areas. Calibration testing was conducted in adult,
pediatric, and parent proxy samples. A full description is available at
www.Healthmeasures.net/promis
The item calibrations and test statistics provided are all based upon cross-sectional data
collection. Use of PROMIS instruments in clinical research is encouraged, with the
understanding that data collected from that use will contribute to knowledge about the validity of
PROMIS measures. USERS OF PROMIS TOOLS ARE STRONGLY ENCOURAGED TO
SUBMIT A BRIEF REPORT INCLUDING SAMPLE DEMOGRAPHIC INFORMATION,
CLINICAL DATA SUFFICIENT TO DEFINE THE SAMPLE WITHOUT INDICATING
TREATMENT RESPONSE DATA, AND PROMIS SCORE DISTRIBUTIONS (E.G., BASELINE
MEAN AND STANDARD DEVIATIONS OR CHANGE SCORES BLINDED TO TREATMENT
INFORMATION).
This brief report should be submitted to help@assessmentcenter.net for internal review. None of
this submitted information will be published without the written consent and participation of the
submitter. In addition to the brief report, clinical researchers are encouraged to submit de-
identified data for collaborative analysis and reporting. Data ownership would remain with the
submitter. Clinical researchers are strongly encouraged to collaborate with PROMIS
investigators when applying these items and banks to their research.
ANY PUBLICATION OR PRESENTATION OF RESULTS OBTAINED FROM STUDIES

CONDUCTED USING THE PROMIS INSTRUMENTS SHOULD INCLUDE A STATEMENT
THAT INDICATES WHICH PROMIS INSTRUMENTS (INCLUDING VERSION NUMBER)
WERE USED, AND REFERENCE THE PROMIS SITE ( www.Healthmeasures.net/promis) FOR
FURTHER INFORMATION. PERMISSION TO USE PROMIS INSTRUMENTS DOES NOT
GRANT PERMISSION TO MODIFY THE WORDING OR LAYOUT OF ITEMS, TO
DISTRIBUTE TO OTHERS, OR TO TRANSLATE ITEMS INTO ANY OTHER LANGUAGE.
SUCH PERMISSION TO MODIFY, DISTRIBUTE, OR TRANSLATE MUST BE REQUESTED
FROM THE PROMIS HEALTH ORGANIZATION OR THE OWNER OF THE COPYRIGHTED
MATERIALS FROM WHICH PROMIS HAS BEEN DERIVED.
COPYRIGHT NOTICE AND CLAIMS OF COPYRIGHT INFRINGEMENT

Information and materials contained herein are ©2008-2016 PROMIS Health Organization and
PROMIS Cooperative Group or other individuals/entities that have contributed information and
materials to Assessment Center (www.assessmentcenter.net), and are being used with the
17
permission of the copyright holders. The table set forth below identifies individuals and entities
who have contributed items in support of building PROMIS item banks and the copyrighted
information and materials employed by such persons. As a user of PROMIS you are entirely
responsible for respecting the proprietary rights of such persons, and for complying strictly with
the requirements set forth herein. If you have questions about these requirements and your
legal obligations, you may wish to consult an attorney.
Thomas M. Achenbach, PhD David Cella, PhD

Child Behavior Checklist for Youth Functional Assessment of Chronic Illness
Therapy (FACIT)
Torbjörn Åkerstedt Center on Outcomes, Research, and Education
Karolinska Sleep Diary Item Banks
Stanley E. Althof Larry Chambers, PhD

Center for Marital and Sexual Health Sexual McMaster Health Index Questionnaire
Functioning Questionnaire
Trudie Chadler
Julie Barroso, PhD 14-Item fatigue scale
HIV-Related Fatigue Scale
Ann Coscarelli,
Dorcas Beaton Cancer Rehabilitation Evaluation System
Disabilities of the Arm, Shoulder and Hand (CARES)
(DASH)
Kimberly A. Cote
Basia Belza Brock Sleep and Insomnia Questionnaire
Multidimensional Assessment of Fatigue
Laura Creti
Jill Binkley, PT Sexual History Form
Lower Extremity Functional Scale
Peter Dent, MD
Thomas Borkovec Juvenile Arthritis Self-Report Index (JASI)
Penn State Worry Questionnaire
George Domino
Lynn Breau Assessment of Sleep
Non-communicating Children's Pain Checklist Sleep Questionnaire
Bengt Brorsson Maxime Dougados, MD

Swedish Health Related Quality of Life Survey Dougados Functional Index (DFI)
Richard Brown, PhD Alan B. Douglass

Parkinson Fatigue Scale Sleep Disorders Questionnaire
Elly Budiman-Mak, MD M. Tuncay Duruoz, MD

Foot Function Scale Duruoz Hand Index
Arnold Buss Jack D. Edinger

Buss-Durkee Hostility Inventory Edinger’s Sleep History Questionnaire
Daniel J. Buysse Colin A. Espie

Pittsburgh Sleep Quality Index Beliefs and Attitudes about Sleep Scale
Dysfunctional Beliefs and Attitudes about Sleep
Andrei Calin, MD Scale - 10
Bath Ankylosing Spondylitis Function Index Glasgow Content of Thoughts Inventory
(BASFI) Insomnia Impact Scale
Sleep Disturbance Questionnaire
18
Alan Jette
Jeremy Fairbank, MD AMPAC
Oswestry Low Back Pain Disability
Questionnaire (OLBPDQ) Jeffrey G. Johnson, PhD
Patient Health Questionnaire for Adolescents
Catherine S. Fichten (PHQ-A)
Sleep Diary
Sleep Questionnaire Robert Kerns
WHYMOI
Robert Ficke
Performance Outcomes Measures Project Lauren Krupp
Fatigue Severity Scale
J.D. Fisk Sleep Symptom Questionnaire
Fatigue Impact Scale
Jin-Shei Lai, PhD
James F Fries, MD Pediatric Fatigue Item Bank
Health Assessment Questionnaire (HAQ)
Kathryn A. Lee
Richard Gracely Numerical Rating Scale for Fatigue
Descriptor Differential Scale of Pain Affect (DDS
- Pain Affect item) Stephen J. Lepore
Social Constraint Scale
Johanna CJM de Haes, PhD
Rotterdam Symptom Checklist Debra Lerner, PhD
Work Limitations Questionnaire
Stephen Haley, PhD
Late Life Function and Disability Instrument: Kenneth Lichstein
Function Component Sleep Questionnaire
Danete Hann, PhD and Paul Jacobsen, PhD Mark S. Litwin

Fatigue Symptom Inventory UCLA Prostate Cancer Index
Philip S. Helliwell, MD, PhD Daniel Lovell, MD

Revised Leeds Disability Questionnaire Juvenile Arthritis Functional Assessment Scale
Juvenile Arthritis Functional Assessment Report
Ian Hindmarch for Children (JAFAR-C)
Quality of Life of Insomniacs
Leeds Sleep Evaluation Questionnaire (LESQ) Ayala Malach-Pines
Burnout Measure
Mark Hlatky, MD
Duke Activity Status Index (DASI) Ralph Marino, MD
Capabilities of Upper Extremity (CUE)
Timothy J. Hoelscher
Insomnia Impact Scale Robert Meenan, MD
Arthritis Impact Measurement Scales 2 (AIMS2)
William L. Holzemer
PPBL Tito Mendoza, Charles Cleeland
MD Anderson Symptom Inventory
E. Scott Huebner, PhD
Multidimensional Students’ Life Satisfaction Charles M. Morin
Scale (MSLSS) Insomnia Interview Schedule
Sleep Diary
Paul Jacobsen
Fatigue Symptom Inventory Douglas E. Moul
Pittsburgh Insomnia Rating Scale
19
Nikolaus Netzer Judith Siegel, PhD
Berlin Questionnaire Multidimensional Anger Inventory
Geraldine Padilla Ann Skinner

Quality of Life Scale – Cancer Sickness Impact Profile (SIP)
Tonya M. Palermo, PhD John Spertus, MD, MPH

Child Activity Limitations Interview (CALI) Seattle Angina Questionnaire
George Parkerson, MD Charles D. Spielberger, PhD

Duke Health Profile State-Trait Anger Expression Inventory (STAXI)
Donald Patrick, PhD Barbara Starfield, MD, MPH

WHOQOL-100 US Version Child Health and Illness Profile – Adolescent
Edition (CHIP-AE)
Arnold L. Potosky
Prostate Cancer Outcomes Study Kevin Stein
Multidimensional Fatigue Symptom Inventory
Jack D. Edinger, Professional Resource
Exchange K.L. Syrjala
Edinger's Sleep History Questionnaire Sexual Function Questionnaire
Quentin R. Regestein Peter Tugwell, MD

Hyperarousal Scale McMaster Toronto Arthritis
Robin Richards, MD David Tulsky, PhD

American Shoulder and Elbow Surgeons SCI-QOL
Shoulder Form (ASES) TBI-QOL
J. Scott Richards James W. Varni, PhD

UAB Pain Behavior Scale PedsQL™ Arthritis Module Version 3.0 Child
Report (ages 8-12)
Tracey Riseborough PedsQL™ Asthma Module Version 3.0 Child
Hospital Anxiety and Depression Scale (HADS) Report (ages 8-12)
PedsQL™ Cerebral Palsy Module Version 3.0
Kathryn Roach, PhD Child Report (ages 8-12)
Shoulder Pain and Disability Index PedsQL™ Multidimensional Fatigue Scale
Standard Version Child Report (ages 8-12)
Martin Roland, MA, MRCP PedsQL™ Pediatric Quality of Life Inventory
Roland-Morris Low Back Pain and Disability Version 4.0 Child Report (ages 8-12)
Questionnaire
Johan W. S. Vlaeyen
Raymond Rosen and Jules Mitchell Checklist for Interpersonal Pain Behavior
Brief Index of Sexual Functioning for Women
Female Sexual Function Index John Ware, PhD
PIQ-6
Thomas Roth SF-36 v2
Global Sleep Assessment Questionnaire Medical Outcomes Study Sexual Functioning
Scale
Daniel W. Russell
UCLA Loneliness Scale Terri E. Weaver
Debra Sciabarrasi Functional Outcomes of Sleep Questionnaire
Barthel Index
Wilse B. Webb
Cathy Sherbourne, Robert Brook, Brent Bradley Post-Sleep Inventory
Rand-36 Index of Vitality
20
Nadine Weisscher
AMC Linear Disability Score (ALDS) Horng-Shiuann Wu, PhD
Nick Wetton Cancer-Related Fatigue Instrument
Crown-Crisp Experiential Index
21
Appendix 2 – Determining Handedness
If a participant does not know or cannot tell the examiner his/her handedness, the following
questions should be used to determine it:
a. Which foot do you use to kick a ball? Left/Right

b. Which hand do you use to pick up and throw a ball? Left/Right
c. Which hand do you use to write or draw? Left/Right
Whichever is selected at least two times, from the above three questions (right or left) is
determined to be the dominant hand.
22
Appendix 3 – Pausing, Stopping, Resuming Rules
Different instruments may behave differently if “Resume Instrument” is selected. In most cases,
users will be taken back to where they were before pausing the assessment. In some cases
(e.g., timed tests), users will be taken back to the beginning of the instrument. In select cases,
an instrument may not be restarted once paused. Detailed rules for skipping, pausing or
stopping each test are provided below.
Cognition
NIH Toolbox Picture Vocabulary Test
• Skip
o Resume not allowed- mark instrument as "completed,” go to next instrument (if
applicable). Can never be restarted.
• Pause (perform admin gesture, and return to instrument without selecting ‘stop’ or ‘skip’)
o During Instructions
 Return to active screen; pause not recorded in data
o During Practice
o During Live Items
• Stop (exit the instrument by selecting ‘stop’ with the intention of resuming at a later time)
o During instructions
 Participant sees first item (aka resume at beginning of instrument).
Previous data are overwritten.
o During Practice
o During Live Items
 Participant sees item equivalent to last item shown. Dichotomous engine
will find the un-administered item whose difficulty setting is closest to the
user’s theta, which will be used for restarting. On restart, the engine is
provided with the user’s existing theta score (instead of the starting theta
value).
NIH Toolbox Flanker Inhibitory Control and Attention Test

• Skip
o Resume not allowed- mark instrument as "completed," go to next instrument (if
o During Practice
o During Live Items
23
o During Practice
 Participant sees last practice item not responded to.
o During Live Items
 Participant sees last live item not responded to.
NIH Toolbox List Sorting Working Memory Test

• Skip
o During Practice
o During Live Items

o During Practice
o During Live Items
 Participant sees last live item not responded to. This restart will also
always play the list’s introduction screen before showing the screens
again.
NIH Toolbox Dimensional Change Card Sort Test
• Skip
o During Practice
o During Live Items
24
o During Practice
o During Live Items
NIH Toolbox Pattern Comparison Processing Speed Test
• Skip
o During Practice
o During Live Items

 Resume not allowed- mark instrument as "completed,” go to next
instrument (if applicable).
o During Practice
o During Live Items

NIH Toolbox Picture Sequence Memory Test

• Skip
o During Practice
o During Live Items

o During Practice
 If the user stops during the first practice item, they will return to the start
of the instrument. If the user stops during the second practice item they
25
will return to the last sequence they did not respond to; this includes that
sequence’s introduction.
o During Live Items
 If the user stops during a live item, they will return to the last sequence
they did not respond to; this includes that sequence’s introduction.
NIH Toolbox Oral Reading Recognition Test

• Skip
o During Practice
 NO PRACTICE IN OR
o During Live Items
o During Practice
 NO PRACTICE IN OR
o During Live Items
 Participant sees item equivalent to last item shown. Dichotomous engine
will find the un-administered item whose difficulty setting is closest to the
user’s theta, which will be used for restarting. On restart, the engine is
provided with the user’s existing theta score (instead of the starting theta
value).
26
Emotion
Emotion Fixed Form

• Skip
o During Practice
 NO PRACTICE IN EMOTION
o During Live Items
o During Practice
o During Live Items
Emotion CAT
• Skip
o During Practice
o During Live Items
o During Practice
o During Live Items
 Participant sees item equivalent to last item shown
27
Motor
NIH Toolbox 9-Hole Pegboard Dexterity Test

• Skip
o During Practice
o During Live Items

o During Practice
o During Live Items
NIH Toolbox Grip Strength Test

• Skip
o During Practice
o During Live Items

o During Practice
o During Live Items
28
NIH Toolbox Standing Balance Test
• Skip
o During Practice
o During Live Items

o During Practice
o During Live Items
NIH Toolbox 4-meter Walk Gait Speed Test

• Skip
o During Practice
o During Live Items

instrument (if applicable). Can never be restarted
o During Practice
29
o During Live Items

NIH Toolbox 2-Minute Walking Endurance Test
o During Practice
 NO PRACTICE ITEMS IN ENDURANCE TEST
o During Live Items
 Resume not allowed- mark instrument as "completed", go to next


o During Practice
 NO PRACTICE ITEMS IN ENDURANCE TEST
o During Live Items
 Resume not allowed- mark instrument as "completed", go to next

Sensation
NIH Toolbox Pain Intensity Fixed Form

• Skip
o During Practice
30
 NO PRACTICE IN PAIN INTENSITY
o During Live Items
o During Practice
 NO PRACTICE IN PAIN INTENSITY
o During Live Items
NIH Toolbox Pain Interference CAT
• Skip
o Resume not allowed- mark instrument as "completed,” go to next
instrument (if applicable). Can never be restarted.
• Pause (perform admin gesture, and return to instrument without selecting ‘stop’
or ‘skip’)
o During Practice
 NO PRACTICE IN PAIN INTERFERENCE
o During Live Items
• Stop (exit the instrument by selecting ‘stop’ with the intention of resuming at a
later time)
o During Practice
 NO PRACTICE IN PAIN INTERFERENCE
o During Live Items
 Participant sees item equivalent to last item shown
NIH Toolbox Odor Identification Test

• Skip
31
o During Practice
o During Live Items
o During Practice
o During Live Items
NIH Toolbox Visual Acuity Test
• Skip
o Resume not allowed – mark instrument as “completed,” go to next
instrument (if applicable). Can never be restarted.
• Pause (perform admin gesture, and return to instrument without selecting ‘stop’
or ‘skip’)
o During Practice/Screening
o During Live Items
• Stop (exit the instrument by selecting ‘stop’ with the intention of resuming at a
later time)
o During Practice/Screening
 Participant sees item from last optotype size not responded to.
32
o During Live Items
 Participant sees item equivalent to last item shown.
NIH Toolbox Words-In-Noise Test

• Skip
o During Practice
 NO PRACTICE ITEMS IN WIN TEST
o During Live Items

o During Practice
 NO PRACTICE ITEMS IN WIN TEST
o During Live Items

NIH Toolbox NIH Toolbox Regional Taste Intensity Test
• Skip

o During Practice
o During Live Items
33

o During Practice

o During Live Items
34
Appendix 4 – NIH Toolbox Equipment and Materials
In most cases when using the NIH Toolbox app, all you will need to administer the tests and
surveys to participants is an iPad. However, there are some additional supplies needed for the
cognition, motor and sensation instruments as outlined below. Keep in mind the following
guidelines when purchasing additional supplies:
1. Unless recommended otherwise, all materials and equipment can be
purchased from any vendor of your choosing.
2. Adhere to the minimum requirements for the materials and equipment where
applicable.
3. Some materials and equipment can be reused for multiple tests (e.g., Bluetooth
wireless keyboard).
4. Vendors may provide discounts for educational institutions, non-profits, etc.
General recommended equipment and materials:

An iPad case that allows for different viewing angles and provides protection is recommended.
The links below provide examples of recommended cases, for use during administration of any
or all instruments:
1. http://www.otterbox.com/en-us/ipad-cases
2. http://www.logitech.com/en-us/product/blok-protective-
case?wt.ac_id=global_news_blokcase_081515
If a less expensive alternative is desired (and young children are not being tested), here is a link
to an example of a recommended case:
http://www.apple.com/shop/product/MGTM2ZM/A/ipad-air-smart-cover-
black?fnode=a87dbdead2a27022cf9ab0e35304a975132e244355b424ba4a40d2b00bedcc62c3
e99c0671951dea0e39b200113ed409bda611c17ef86559beeb743d176f9bf428f3847c4c361f27c
478b04af1540e623b25db8c477687d51c63802fa11df130e4e7decbc26fddbde805d751bbf55deb
35
NIH Toolbox Cognition instruments additional equipment and materials:
Equipment and
Instrument Vendor Suggestion Approximate Cost
Materials
NIH Toolbox Picture
None --- ---
Vocabulary Test
NIH Toolbox Flanker
Download from NIH
Inhibitory Control and Home Base Free
Toolbox Website
Attention Test
Bluetooth Wireless
Apple Store $69.00
Keyboard
Extra AA batteries for
Any Varies
NIH Toolbox List the keyboard
Sorting Working NIH Toolbox List
Memory Test Sorting Working Contact
Memory Test cognition@nihtoolbox Free
Examiner Answer .org
Sheet
NIH Toolbox
Download from NIH
Dimensional Change Home Base Free
Toolbox Website
Card Sort Test
NIH Toolbox Pattern
Comparison
None --- ---
Processing Speed
Test
NIH Toolbox Picture
Sequence Memory None --- ---
Test
Bluetooth Wireless
Apple Store $69.00
Keyboard
Extra AA batteries for
NIH Toolbox Oral Any Varies
the keyboard
Reading Recognition
NIH Toolbox Oral
Test Contact
Reading Recognition
cognition@nihtoolbox Free
Test Training and
.org
Certification Materials
NIH Toolbox Emotion instruments additional equipment and materials:

None
36
NIH Toolbox Motor instruments additional equipment and materials:
Vendor Approximate
Instrument Equipment/Materials
Suggestion Cost
Jamar® 9-Hole Peg
Test Kit (item number
A8515) Patterson Medical $80.75
NIH Toolbox 9-hole (also known as Rolyan
Pegboard Dexterity 9-hole Peg Test Kit)
Test Jamar® 9-Hole Peg
Test Kit Replacement
Patterson Medical $11.65
Pegs (item number
A8516)
Jamar® Plus+ Digital
NIH Toolbox Grip
Hand Dynamometer Patterson Medical $363.55
Strength Test
(item number 563213)
iPod touch (5th
Apple Store $199.00
generation or later)
Griffin Survivor
protective case (part # CDW Varies
3611154) or similar
NIH Toolbox AIREX Balance Pad
Medex Supply or
Standing Balance Elite (item number $69.00
Amazon
Test ARX-23431)
Scott Gait Belt
w/Velcro (item number
Promedxpress $14.99-19.99
177 0089, various
sizes)
Sanitary booties Any Varies
Any. Sufficient to
Measuring tape with
set up a 50’ Varies
meters and feet
NIH Toolbox 4 Meter walking course.
Walk Gait Speed Test Any. Small plastic
Set of 2 cones Varies
and cones..
Walking course set up
See Appendix 6 Free
2-Minute Walk diagram.
Endurance Test Colored masking tape
to set up the walking Any Varies
course
37
NIH Toolbox Sensation instruments additional equipment and materials:
Vendor Approximate
Instrument Equipment/Materials
Suggestion Cost
NIH Toolbox Pain
None --- ---
Interference Test
NIH Toolbox Pain
None --- ---
Intensity Test
Download ordering
NIH Toolbox Odor instructions from Varies by the
NIH Toolbox Odor Identification Cards NIH Toolbox size of the order
Identification Test Website
Scratcher (e.g., guitar
Any $0.25
pick)
Belkin Portable Tablet
www.cdw.com $97.99
Stage or similar
Bluetooth Wireless
Apple Store $69.00
Keyboard
NIH Toolbox Visual
Table Any Varies
Acuity Test
Measuring Tape Any Varies
Laminated HOTV
letters for young Download here Free
children
Sennheiser HD201
headphones or any
others that meet or
exceed these
specifications:
Bandwidth/Frequency
Response:
10 Hz – 10,000 Hz Varies.
NIH Toolbox Words- Any vendor or
Isolation = 10 dB or Approximately
in-Noise (WIN) Test Headphone.com
Greater Sensitivity: $30.00
96 dB SPL/V or
greater.
Standard phone/laptop
plug
(3.5 mm)
Please refer to
NIH Toolbox
Appendix 7 for the
Regional Taste Test
detailed list of materials
38
Appendix 5 – Key to Instrument Name Abbreviations
Corresponding Instrument Name

Title screen displayed in the app
NIH Toolbox Touch Screen Tutorial 3+ NIH Toolbox Touch Screen Tutorial Age 3+
NIH Toolbox PVT 3+ NIH Toolbox Picture Vocabulary Test Age 3+
v2.0
NIH Toolbox OR 3+ NIH Toolbox Oral Reading Recognition Test
Age 3+ v2.0
NIH Toolbox LS 7+ NIH Toolbox List Sorting Working Memory
Test Age 7+ v2.0
NIH Toolbox PC 7+ NIH Toolbox Pattern Comparison Processing
Speed Test Age 7+ v2.0
NIH Toolbox PSM 3-4 Form A NIH Toolbox Picture Sequence Memory Test
Ages 3-4 Form A v2.0
NIH Toolbox PSM 3-4 Form B NIH Toolbox Picture Sequence Memory Test
Ages 3-4 Form B v2.0
NIH Toolbox PSM 3-4 Form C NIH Toolbox Picture Sequence Memory Test
Ages 3-4 Form C v2.0
NIH Toolbox PSM 7 Form A NIH Toolbox Picture Sequence Memory Test
Age 7 Form A v2.0
NIH Toolbox PSM 7 Form B NIH Toolbox Picture Sequence Memory Test
Age 7 Form B v2.0
NIH Toolbox PSM 7 Form C NIH Toolbox Picture Sequence Memory Test
Age 7 Form C v2.0
NIH Toolbox PSM 8+ Form A NIH Toolbox Picture Sequence Memory Test
Age 8+ Form A v2.0
NIH Toolbox PSM 8+ Form B NIH Toolbox Picture Sequence Memory Test
Age 8+ Form B v2.0
NIH Toolbox PSM 8+ Form C NIH Toolbox Picture Sequence Memory Test
Age 8+ Form C v2.0
NIH Toolbox FL 3-7 NIH Toolbox Flanker Inhibitory Control and
Attention Test Ages 3-7 v2.0
NIH Toolbox FL 12+ NIH Toolbox Flanker Inhibitory Control and
Attention Test Age 12+ v2.0
NIH Toolbox DCCS 3-7 NIH Toolbox Dimensional Change Card Sort
Test Ages 3-7 v2.0
39
Test Ages 8-11 v2.0
NIH Toolbox DCCS 12+ NIH Toolbox Dimensional Change Card Sort
Test Age 12+ v2.0
NIH Toolbox 4-Meter Walk Gait Speed Test NIH Toolbox 4-Meter Walk Gait Speed Test
7+ Age 7+ v2.0
NIH Toolbox 9-Hole Pegboard Dexterity Test NIH Toolbox 9-Hole Pegboard Dexterity Test
3+ Age 3+ v2.0
NIH Toolbox Grip Strength Test 3+ NIH Toolbox Grip Strength Test Age 3+ v2.0
NIH Toolbox Standing Balance Test 3-6 NIH Toolbox Standing Balance Test Ages 3-6
v2.0
NIH Toolbox Standing Balance Test 7+ NIH Toolbox Standing Balance Test Age 7+
v2.0
NIH Toolbox 2-Minute Walk Endurance Test NIH Toolbox 2-Minute Walk Endurance Test
3+ Age 3+ v2.0
NIH Toolbox Odor Identification Test 10+ NIH Toolbox Odor Identification Test Age 10+
v2.0
NIH Toolbox Odor Identification Test 3-9 NIH Toolbox Odor Identification Test Ages 3-
9 v2.0
NIH Toolbox Words-In-Noise Test 6+ NIH Toolbox Words-In-Noise Test Age 6+
v2.1
NIH Toolbox Regional Taste Test 12+ NIH Toolbox Regional Taste Intensity Test
Age 12+ v2.0
NIH Toolbox Visual Acuity Test 3-7 NIH Toolbox Visual Acuity Test Ages 3-7 v2.0
NIH Toolbox Visual Acuity Test 8+ NIH Toolbox Visual Acuity Test Age 8+ v2.0
NIH Toolbox Dynamic Visual Acuity Test 3-7 NIH Toolbox Dynamic Visual Acuity Test
Ages 3-7 v2.0
NIH Toolbox Dynamic Visual Acuity Test 8+ NIH Toolbox Dynamic Visual Acuity Test Age
8+ v2.0
NIH Toolbox Pain Intensity FF Age 18+ NIH Toolbox Pain Intensity FF Age 18+ v2.0
NIH Toolbox Pain Interference CAT Age 18+ NIH Toolbox Pain Interference CAT Age 18+
v2.0
NIH Toolbox Touch Screen Tutorial 3+ NIH Toolbox Touch Screen Tutorial Age 3+
NIH Toolbox PVT 3+ NIH Toolbox Picture Vocabulary Test Age 3+
v2.0
NIH Toolbox OR 3+ NIH Toolbox Oral Reading Recognition Test
Age 3+ v2.0
NIH Toolbox LS 7+ NIH Toolbox List Sorting Working Memory
Test Age 7+ v2.0
NIH Toolbox PC 7+ NIH Toolbox Pattern Comparison Processing
Speed Test Age 7+ v2.0
40
NIH Toolbox PSM 7 Form A NIH Toolbox Picture Sequence Memory Test
Age 7 Form A v2.0
NIH Toolbox PSM 7 Form B NIH Toolbox Picture Sequence Memory Test
Age 7 Form B v2.0
NIH Toolbox PSM 7 Form C NIH Toolbox Picture Sequence Memory Test
Age 7 Form C v2.0
NIH Toolbox PSM 8+ Form A NIH Toolbox Picture Sequence Memory Test
Age 8+ Form A v2.0
NIH Toolbox PSM 8+ Form B NIH Toolbox Picture Sequence Memory Test
Age 8+ Form B v2.0
NIH Toolbox PSM 8+ Form C NIH Toolbox Picture Sequence Memory Test
Age 8+ Form C v2.0
NIH Toolbox FL 12+ NIH Toolbox Flanker Inhibitory Control and
Attention Test Age 12+ v2.0
Test Ages 3-7 v2.0
Test Ages 8-11 v2.0
NIH Toolbox DCCS 12+ NIH Toolbox Dimensional Change Card Sort
Test Age 12+ v2.0
NIH Toolbox 4-Meter Walk Gait Speed Test NIH Toolbox 4-Meter Walk Gait Speed Test
7+ Age 7+ v2.0
NIH Toolbox 9-Hole Pegboard Dexterity Test NIH Toolbox 9-Hole Pegboard Dexterity Test
3+ Age 3+ v2.0
NIH Toolbox Grip Strength Test 3+ NIH Toolbox Grip Strength Test Age 3+ v2.0
NIH Toolbox Standing Balance Test 3-6 NIH Toolbox Standing Balance Test Ages 3-6
v2.0
NIH Toolbox Standing Balance Test 7+ NIH Toolbox Standing Balance Test Age 7+
v2.0
NIH Toolbox 2-Minute Walk Endurance Test NIH Toolbox 2-Minute Walk Endurance Test
3+ Age 3+ v2.0
NIH Toolbox Odor Identification Test 10+ NIH Toolbox Odor Identification Test Age 10+
v2.0
41
NIH Toolbox Odor Identification Test 3-9 NIH Toolbox Odor Identification Test Ages 3-
9 v2.0
NIH Toolbox Words-In-Noise Test 6+ NIH Toolbox Words-In-Noise Test Age 6+
v2.1
NIH Toolbox Regional Taste Test 12+ NIH Toolbox Regional Taste Intensity Test
Age 12+ v2.0
NIH Toolbox Visual Acuity Test 3-7 NIH Toolbox Visual Acuity Test Ages 3-7 v2.0
NIH Toolbox Visual Acuity Test 8+ NIH Toolbox Visual Acuity Test Age 8+ v2.0
NIH Toolbox Dynamic Visual Acuity Test 3-7 NIH Toolbox Dynamic Visual Acuity Test
Ages 3-7 v2.0
NIH Toolbox Dynamic Visual Acuity Test 8+ NIH Toolbox Dynamic Visual Acuity Test Age
8+ v2.0
42
Appendix 6 – NIH Toolbox 4-Meter Walk Gait Speed Test and 2-
Minute Walk Endurance Test Walking Course
The NIH Toolbox Four-Meter Walk Gait Speed Test and Two-Minute Walk Endurance Test each
use walking courses. The walking courses differ from each other but, if both measures are being
administered, the courses can be laid out at the same time.
• Tape measure with both feet and meter measurements
• Colored masking tape
• Two cones
• Chair
If administering the Two-minute Walk Endurance Test, you need an open space of at least 60
feet in length.
Following the schematic diagram attached, at 5 feet from the start, put a piece of tape 2’ to 3’ long
across the hallway.
Put shorter pieces of tape at four 10-foot intervals from that piece of tape.
At the fifth 10-foot interval, put another piece of tape 2’ to 3’ long across the hallway.
If administering the Four-Meter Walk Gait Speed Test, you can superimpose the course on the
course above or make another course.
Following the schematic diagram attached, at 5 feet from the start, put a piece of tape 2’ to 3’ long
across the hallway.
Measure 4 meters from the piece of tape, and put another piece of tape 2’ to 3’ long across the
hallway.
Lastly, measure 1 meter from that piece of tape and put another piece of tape 2’ to 3’ long across
the hallway.
For the Two-minute Walk Endurance Test, the cones should be placed at the sides of the first
long mark and the last long mark of that course.
For the Four-Meter Walk Gait Speed Test, the cones should be placed at the side of the first
long mark and the last long mark of that course.
For both measures, a chair should be placed near the beginning of the course.
43
44
Appendix 7 – NIH Toolbox Regional Taste Test Materials and
Taste Solutions Mixing Instructions

An electronic balance (scale) readable to at least 0.01 grams, and preferably 0.001 grams
Examples: Ohaus Aventurer Pro Series or Denver Instrument Summit Series prices run around
$1000+
Magnetic stirrer
Example: Fisher Scientific Isotemp Basic Magnetic Stirrer 7 x 7 in, 120 volt price is $295
Stir bar (1 or 1.5 inches in length)
Example: Fisher Scientific Stir Bars 9.5 dia X 25.4 mm L price $7.79
Plastic-coated magnetic retrieving rod
Example: Fisher Brand Stir Bar Retriever, 12 inch price $16.27 each
A 1-liter graduated cylinder
Example: Fisherbrand Serialized Class A Graduated Cylinder price $169.42 each. A more
affordable Polypropylene graduated cylinder is an option if cost is factor.
Solution storage bottles, light-occluding are required for quinine
Example: Pyrex Brown Solution Storage Bottles price for case of four 500 ml bottles is $173.65
A lab spoon
Example: Fisherbrand Lab Spoon price $13.93 each
Plastic weigh boats
Example: Anti-Static Weighing Boats price for small (needed for quinine) $39 for 500, price for
large (needed for NaCl) $83.50 for 500
Food, Kosher or USP grade Quinine monohydrochloride dihydrate.
Example: Aldrich Quinine monohydrochloride dihydrate price: $58 for 100 grams.
USP grade NaCl
Example: Spectrum Sodium Chloride Granular, USP price: $174.70 per 2.5 kg. Can also be
ordered in bulk.
Distilled or deionized water
Example: EartH2O Distilled Water available in grocery stores, prices vary by location
Note: NIH Toolbox norms were collected using USP grade NaCl (formula weight 58.44) available from
Spectrum Chemicals and Kosher grade quinine monohydrochloride dihydrate (formula weight 396.9)
available from Sigma-Aldrich.
45
Sterile cotton swabs
Distilled, deionized or other purified water for rinsing.
Example: Aquafiina. Dasani is NOT recommended because minerals are added back in after
the purification.
Spittoon
iPad stand
Example: Belkin Portable Tablet Stage, price $97.99
Mixing instructions:
Make sure that balance is on a level surface. Add weigh boat to balance pan, and carefully zero
the balance. Then add 58.44 grams of NaCl to the weigh boat. To mix the 1 Molar NaCl
solution, you will need to add the NaCl to 1 liter of purified water. To do this, place pre-
measured NaCl crystals in a 1-liter graduated cylinder. Make sure all the crystals are emptied
from the weigh boat into the graduated cylinder. Slowly add distilled or deionized water to the 1-
liter mark by bringing the meniscus (bottom) of the solution to the 1000 ml mark. Gently add the
stir bar and then stir on a magnetic stirrer until the NaCl is completely dissolved (approximately
5 to 10 minutes). Once NaCl is fully dissolved, turn off the stirrer, and use the retrieving rod to
remove the stir bar from the solution. Transfer the solution to labeled storage bottles. Wash
and rinse graduated cylinder, stir bar, and retrieving rod thoroughly before reusing.
To mix 0.001 M quinine hydrochloride dihydrate, dissolve 0.397 grams quinine in purified water.
To do this, weigh out 0.397 grams of quinine HCl dihydrate as described above. If you do not
have access to an analytical balance that goes to four decimal points, weigh out 0.40 grams of
quinine HCl on a standard top-loading electronic balance. Do not use a triple-beam balance for
quinine. Place the pre-measured quinine in a 1-liter cylinder, add distilled or deionized water to
the 1000 milliliter mark, gently add the stir bar and then stir on a magnetic stirrer until the
quinine is completely dissolved, and no visible crystals can be seen (at least 15 to 20 minutes).
Transfer the solution to labeled storage bottles. When finished, wash and rinse graduated
cylinder, stir bar, and retrieving rod thoroughly before reusing.
Solution Storage Requirements:
Taste solutions should be made fresh each week, stored under refrigeration when not in use,
and should be warmed to room temperature prior to use for testing. Please do not freeze the
solutions because the container may crack (Note: 3-4 hours is generally required for solutions to
warm to room temperature.)
Taste solutions should be stored in glass bottles with a non-reactive lid. Quinine is light
sensitive, so quinine should be stored in a light-occluding glass bottle or a bottle wrapped in
aluminum foil to minimize light exposure.
Use of Solutions for Taste Testing:

Each participant will be tested with 10 ml of quinine solution and 10 ml of NaCl solution.
Solutions should be at room temperature for testing. Two labeled medicine cups should be
46
used to hold the solutions for testing each participant. 10 ml of quinine solution should be
poured into one cup and 10 ml of NaCl solution should be poured into the second cup.
For tongue tip testing, a clean cotton swab will be dipped once in the quinine solution and then
used to paint the solution across the anterior tongue.
After the participant rinses his/her mouth, a second clean cotton swab will be dipped once in the
NaCl solution and used to paint the solution across the anterior tongue.
The solution remaining in each of the two cups will then be used for whole-mouth testing, first
with quinine and then with NaCl.
47

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NIH Toolbox® for Assessment of

Neurological and Behavioral Function

iPad App Version 1.17 and up

© 2006-2018 National Institutes of Health and Northwestern University

A.1 What is the NIH Toolbox App?

A.2 Development of the NIH Toolbox

A.3 Characteristics of the NIH Toolbox App

• Takes advantage of portable, easy-to-use technology

B.1 NIH Toolbox App Structure

Introduction – Domain, Battery, Instrument

How to Create an Apple ID on your iPad

How to create an Apple ID on your computer (Apple or Windows operating systems)

1. Tap on the App Store icon on your iPad.

B.3 NIH Toolbox Support

B.4.1 NIH Toolbox App at a Glance

Create a new participant

Step 2: Complete the new participant information:

Step 3: Select from the 3 options presented on the screen:

View Existing Batteries (Preset and Custom)

Step 1: Tap the Batteries button.

Archiving Custom Batteries

Batteries can be archived, or unarchived, at any time.

On the Batteries & Profiles Screen, swipe

On the Batteries & Profiles Screen, select

Step 1: Select the files to export by using the filtering options.

• Registration data (contains participant information entered on this iPad)

Step 4: Tap one of 4 symbols (envelope, iCloud, iTunes, web).

• Set up iCloud following the instructions at https://www.apple.com/icloud/setup/ios.html.

Sample of web service implementation in .NET (c#):

• View and apply for Access to Cognition tests

Data Base Back Up

Early Childhood Cognition Battery

The amount of time it takes to mentally process a set amount of

C.2.1 NIH Toolbox Picture Vocabulary Test

Equipment and materials needed:

Developmental Extension (DEXT ages 3-7):

Age-specific test instructions:

Title Screen NIH Toolbox FL 3-7 E touches and holds button to

Transition to Now you try. E reads screen; then touches

Transition to Now you try. E reads screen; then touches

Test ends, if less than 3 out of 4 correct on set 3

PRACTICE Here is a Fish! E points to screen; then touches and

The fish is pointing this way, the same

You should always choose the button

Keep your eyes on the star in the

Practice items 5 practice items

If less than 4 out Moves to developmental extension

Test items 20 test items (fish)

If < 9 congruent Moves to developmental extension

In this game, put your finger back on

You should always choose the button

20 test items (arrows)

DEXT Screens 4- 5 practice items with fish bowl on screen

If correct, bubbles sound plays and iPad

If less than 4 of 5 correct on screens 12-16, test is discontinued.

After screen 39, DEXT ends.

Title Screen NIH Toolbox FL 8-11 E touches and holds

Transition to Now you try. E reads screen; then

If you make a mistake, just keep going!