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Objectives: To determine base rates of invalid performance on the Test of Memory Malingering (TOMM) in patients with traumatic brain injury (TBI) undertaking rehabilitation who were referred for clinical assessment, and the factors contributing to TOMM failure. Methods: Retrospective file review of consecutive TBI referrals for neuropsychological assessment over seven years. TOMM failure was conventionally defined as performance <45/50 on Trial 2 or Retention Trial. Demographic, injury, financial compensation, occupational, and medical variables were collected. Results: Four hundred and ninety one TBI cases (Median age = 40 years [IQR = 26–52], 79% male, 82% severe TBI) were identified. Overall, 48 cases (9.78%) failed the TOMM. Logistic regression analyses revealed that use of an interpreter during the assessment (adjusted odds ratio [aOR] = 8.25, 95%CI = 3.96–17.18), outpatient setting (aOR = 4.80, 95%CI = 1.87–12.31) and post-injury psychological distress (aOR = 2.77, 95%CI = 1.35–5.70) were significant multivariate predictors of TOMM failure. The TOMM failure rate for interpreter cases was 49% (21/43) in the outpatient setting vs. 7% (2/30) in the inpatient setting. By comparison, 9% (21/230) of non-interpreter outpatient cases failed the TOMM vs. 2% (4/188) of inpatient cases. Conclusions: TOMM failure very rarely occurs in clinical assessment of TBI patients in the inpatient rehabilitation setting. It is more common in the outpatient setting, particularly in non-English-speaking people requiring an interpreter. The findings reinforce the importance of routinely administering stand-alone performance validity tests in assessments of clinical TBI populations, particularly in outpatient settings, to ensure that neuropsychological test results can be interpreted with a high degree of confidence. [ABSTRACT FROM AUTHOR]

Objective This study examined the relative contribution of performance and symptom validity in litigating adults with traumatic brain injury (TBI), as a function of TBI severity, and examined the relationship between self-reported emotional symptoms and cognitive tests scores while controlling for validity test performance. Method Participants underwent neuropsychological assessment between January 2012 and June 2021 in the context of compensation-seeking claims related to a TBI. All participants completed a cognitive test battery, the Personality Assessment Inventory (including symptom validity tests; SVTs), and multiple performance validity tests (PVTs). Data analyses included independent t -tests, one-way ANOVAs, correlation analyses, and hierarchical multiple regression. Results A total of 370 participants were included. Atypical PVT and SVT performance were associated with poorer cognitive test performance and higher emotional symptom report, irrespective of TBI severity. PVTs and SVTs had an additive effect on cognitive test performance for uncomplicated mTBI, but less so for more severe TBI. The relationship between emotional symptoms and cognitive test performance diminished substantially when validity test performance was controlled, and validity test performance had a substantially larger impact than emotional symptoms on cognitive test performance. Conclusion Validity test performance has a significant impact on the neuropsychological profiles of people with TBI, irrespective of TBI severity, and plays a significant role in the relationship between emotional symptoms and cognitive test performance. Adequate validity testing should be incorporated into every neuropsychological assessment, and associations between emotional symptoms and cognitive outcomes that do not consider validity testing should be interpreted with extreme caution. [ABSTRACT FROM AUTHOR]

Objective: We developed the Shell Game Task (SGT) as a novel Performance Validity Test (PVT). While most PVTs use a forced-choice paradigm with "memory" as the primary domain being assessed, the SGT is a face-valid measure of attention and working memory. We explored the accuracy of the SGT to detect noncredible performance using a simulatordesign study. Participants and Methods: Ninety-four university students were randomly assigned to either best effort (CON) (n=49) or simulating traumatic brain injury (TBI) (SIM) (n=45) conditions. Participants completed a full battery of neuropsychological tests to simulate an actual evaluation, including the Test of Memory Malingering (TOMM) and the SGT. The SGT involves three cups and a red ball shown on the screen. Participants watch as the ball is placed under one of the three cups. Cups are then shuffled. Participants are asked to track the cup that contains the ball and correctly identify its location. We created two difficulty levels (easy vs hard, 20 trials each) by changing the number of times the cups were shuffled. Participants were given feedback (correct vs incorrect) after each trial. At the conclusion of the study, participants were asked about adherence to study directions they were given. Results: Participants with missing data (CON=1; SIM=2) or who reported non-adherence to study directions (CON=2; SIM=1) were removed from analyses. Twenty-five percent in SIM and 0% in CON failed TOMM Trial 2 (<45) suggesting adequate manipulation of groups. Groups were not different in age, gender, ethnicity, or education (all p's>.05). There were 9 participants in each group with concussion/TBI history. TBI history was not significantly related to performance on the SGT in either group, although participants with TBI history tended to do better. Average performances on TOMM Trial 1 (36.62 vs 47.91, p<.001) and TOMM Trial 2 (37.50 vs 49.71, p<.001) were significantly lower in the SIM group. Performance on SGT was also significantly lower in the SIM group across SGT Total Correct (20.17 vs 24.65 of 40, p=.008), SGT Easy (10.60 vs 13.52 of 20, p=.002), and SGT Hard (9.57 vs 11.13 of 20, p=.068). Mixed ANOVA showed a trend towards significant group by SGT difficulty interaction (F(1,86)=3.41, p=.052, np2=.043). There was steeper decline in performance on SGT Hard compared to SGT Easy for CON. ROC analyses suggested adequate but not ideal sensitivity/specificity: scores <8 on SGT Easy (sensitivity=26%; false positive=11%), <7 on SGT Hard (sensitivity=26%; false positive=7%), and <15 on SGT Total (sensitivity=24%; false positive=9%). Conclusions: These preliminary data indicate the SGT may be able to detect malingered TBI. However, additional development of this measure is necessary. Further refinement of difficulty level may improve sensitivity/specificity (e.g., CON mean performance for SGT Easy trails was 13.52, suggesting the items may be too difficult). This study was limited to an online administration due to COVID, which could have affected results; future studies should test inperson administration of the SGT. In addition, performance in clinical control groups (larger samples of individuals with mild TBI, ADHD) should be tested to better determine specificity for these preliminary cutoffs. [ABSTRACT FROM AUTHOR]

To examine the convergent validity of the Test of Effort (TOE), a performance validity test (PVT) currently under development that employs a two-subtest (one verbal, one visual), forced-choice recognition memory format. A descriptive, correlational design was employed to describe performance on the TOE and examine the convergent validity between the TOE and comparison measures. A sample of 53 individuals with chronic acquired brain injury (ABI) were administered the TOE and three well-validated PVTs (Reliable Digit Span [RDS], Test of Memory Malingering [TOMM] and Dot Counting Test [DCT]). The TOE appeared more difficult than it actually was, suggesting adequate face validity. Medium-to-large correlations were observed between the TOE and established PVTs, suggesting good convergent validity. Provisional cutoff scores are offered based on performance of a subgroup of participants with "sufficient effort." Overall, the TOE shows promise as a PVT measure for clinical use. Future studies with larger and more diverse samples are needed to more fully determine the psychometric characteristics of the TOE. [ABSTRACT FROM AUTHOR]

The Word Memory Test (WMT) assesses non-credible performance in neuropsychological assessment. To mitigate risk of false positives among patients with severe cognitive dysfunction, the Genuine Memory Impairment Profile was derived. Only a modest number of investigations has evaluated classification accuracy among clinical samples, leaving the GMIP's accuracy largely uncertain. Accordingly, a simulation experiment evaluated the classification accuracy of the GMIP in a group of healthy individuals coached to simulate mild traumatic brain injury (TBI) related memory impairment on the WMT. Eighty healthy individuals were randomly assigned to one of the four experimental groups. One group was provided superficial information concerning TBI symptoms (naïve simulators), another was provided extensive information concerning TBI symptoms (sophisticated simulators), and a third group was provided extensive TBI symptom information and tactics to evade detection by performance validity tests (PVT) (test-coached). An honest responding control group was directed to give their best performance. All participants were administered the California Verbal Learning Test-2 (CVLT-2) and the WMT. Among the TBI simulators, 90% of the test-coached, 95% of the sophisticated simulators, and 100% of the naïve simulators were correctly classified as exaggerating memory impairment on the primary WMT indices. The simulator groups performed worse than the honest responding group on the CVLT-2. Of those who exceeded the WMT cutoffs, 60%, 27%, and 6% of the naïve-, sophisticated-, and test-coached simulators manifested the GMIP profile, respectively. The GMIP is apt to misclassify individuals as having genuine memory impairment, especially if a naïve or unsophisticated effort is made to exert non-credible performance. Indeed, individuals who employ the least sophisticated efforts to exaggerate cognitive impairment appear most likely to manifest the GMIP. The GMIP should be used cautiously to discriminate genuine impairment from non-credible performance, especially among people with mild TBI. [ABSTRACT FROM AUTHOR]

While the Neuropsychological Assessment Battery, Screening Module (S-NAB) is a commonly used cognitive screening measure, no composite embedded performance validity test (PVT) formula has yet been described within it. This study sought to empirically derive PVT formulas within the S-NAB using an analog simulation paradigm. Seventy-two university students (M age = 18.92) were randomly assigned to either an Asymptomatic (AS) or simulated mild traumatic brain injury (S-mTBI) group and were administered a neuropsychological test battery that included the S-NAB and standalone and embedded PVTs. The AS group was instructed to perform optimally, and the S-mTBI group received symptom and test coaching to help simulate mTBI-related impairment. Both groups received warnings regarding the presence of PVTs throughout the test battery. Groups showed significant differences (all ps <.001) on all S-NAB domain scores and PVTs. In the S-NAB, the Attention (S-ATT) and Executive Function (S-EXE) domains showed the largest effect sizes (Cohen's ds = 2.02 and 1.79, respectively). Seven raw scores from S-ATT and S-EXE subtests were entered as predictor variables in a direct logistic regression (LR). The model accurately classified 90.3% of cases. Two PVT formulas were described: (1) an exponentiated equation from LR results and (2) an arithmetic formula using four individually meaningful variables. Both formulas demonstrated outstanding discriminability between groups (AUCs =.96–.97) and yielded good classification statistics compared to other PVTs. This study is the first to describe composite, embedded PVT formulas within the S-NAB. Implications, limitations, and appropriate future directions of inquiry are discussed. [ABSTRACT FROM AUTHOR]

Objective: Recent consensus guidelines have advocated for the use of multivariate performance validity assessment on ability-based measures such those used in neuropsychological assessment. Further, previous research has demonstrated that aggregating performance validity indicators may produce superior classification accuracy. The present study builds upon this research by aggregating data from three of the most commonly used performance validity measures (Test of Memory Malingering [TOMM], Rey Fifteen Item Test with recognition trial [FIT plus recognition], and Reliable Digit Span [RDS]) to create a performance validity composite measure in a veteran mild traumatic brain injury (mTBI) population. Participants and Methods: Data of patients evaluated at a VA hospital who had completed the RDS, FIT plus recognition, and TOMM as part of their clinical neuropsychological evaluation were analyzed (n = 20). Two composite performance validity indexes were created: a Single Cutoff Performance Validity Index (SC-PVI), which measures the quantity of failures across performance validity measures (PVMs) by summing the total number of PVM failures, and a Multiple Cutoff Performance Validity Index (MC-PVI) which measures the number of failures as well as degree of failure(s) across measures of performance validity (e.g., a participant would attain a score of 3 if their PVM performance failed to reach a conservative cut point; they would obtain a score of 1 if they met conservative cut point, yet failed to reach a liberal cut point). Results: Only one participant (5%) attained a score of 0 on the SC-PVI (i.e., passing all PVTs using standard cutoffs) and MC-PVI (i.e., passing the most liberal cut points on all three PVMs). Conversely, eight participants (40%) attained a score of 3 on the SC-PVI (i.e., failed all three PVMs) and four participants (20%) attained a score of 9 (i.e., failed the most conservative cut points on all three PVMs). Results showed a significant (p <.001) ordinal association between the two indices (G =.984); however, there was no significant agreement between SC-PVI and MC-PVI models (k = -.087; p =.127). Conclusions: Data revealed discordant findings between the three PVMs utilized. The majority of participants (75%) scored between 2-8 on the MC-PVI, meaning that they did not exceed all liberal cut points or fail all conservative cut points. These "grey area" scores suggest an indeterminate range of performance validity, which cannot be captured by a solitary cut point or neatly classified as pass or fail. The utility of multiple cutoff performance validity models (i.e., aggregating PVMs to consider the severity of failure and number of failures) is that they capture the nuance of these data when determining and discussing the credibility of a profile. Multiple cut point data also highlight how the choice of cutoff influences the outcome of performance validity research and clinical decision making. As such, future research on the classification accuracy of this MC-PVI is needed. [ABSTRACT FROM AUTHOR]

To assess noncredible performance on the NIH Toolbox Cognitive Battery (NIHTB-CB), we developed embedded validity indicators (EVIs). Data were collected from 98 adults (54.1% female) as part of a prospective multicenter cross-sectional study at 4 mild traumatic brain injury (mTBI) specialty clinics. Traditional EVIs and novel item-based EVIs were developed for the NIHTB-CB using the Medical Symptom Validity Test (MSVT) as criterion. The signal detection profile of individual EVIs varied greatly. Multivariate models had superior classification accuracy. Failing ≥4 traditional EVIs at the liberal cutoff or ≥3 at the conservative cutoff produced a good combination of sensitivity (.57 to .61) and specificity (.92 to .94) to MSVT. Combining the traditional and item-based EVIs improved sensitivity (.65 to .70) at comparable specificity (.91 to .95). In conclusion, newly developed EVIs within the NIHTB-CB effectively discriminated between patients who passed versus failed the MSVT. Aggregating EVIs within the same category into validity composites improved signal detection over univariate cutoffs. Item-based EVIs improved classification accuracy over that of traditional EVIs. However, the marginal gains hardly justify the burden of extra calculations. The newly introduced EVIs require cross-validation before wide-spread research or clinical application. (PsycInfo Database Record (c) 2021 APA, all rights reserved). [ABSTRACT FROM AUTHOR]

Introduction: The Groningen Effort Test (GET) is a recently developed performance validity test (PVT) for the identification of noncredible performance in a neuropsychological assessment of attention abilities. Because the majority of already established PVTs are based on memory functions, the GET has the potential to make a valuable contribution to validity testing. Method: The current study examined the utility of the GET in the detection of feigned cognitive dysfunction after acquired brain injury (ABI) and its incremental validity over already established PVTs, namely the Test of Memory Malingering (TOMM), the Dot Counting Test (DCT), and the b Test. Three hundred and forty-eight participants took part in this study, including 58 patients with ABI (stroke or traumatic brain injury), 43 healthy individuals instructed to show normal behavior, and 247 healthy individuals instructed to feign cognitive dysfunction after ABI. Results: With excellent overall classification accuracy, the GET performed close to the level of the TOMM, and superior to the b Test and DCT. Data analyses further revealed that the GET provides additional diagnostic accuracy compared to the b Test and the DCT in the detection of feigned cognitive dysfunction, but has no incremental validity over the TOMM. For each of the four PVTs in this study, diagnostic sensitivity was independent of the simulation strategy used. Conclusions: It is concluded that the GET is an attention-based PVT with promising test characteristics and high diagnostic accuracy in the detection of noncredible cognitive performance using a simulation design. Given the results can be replicated in studies using known-groups methodology, it may be a useful tool for clinical practice to complement neuropsychological assessments of patients with ABI. [ABSTRACT FROM AUTHOR]

The Memory Validity Profile (MVP) is a performance validity test (PVT) designed specifically for pediatric populations and utilizes specific cut-points for identifying noncredible performance at different ages. This study aims to evaluate the MVP using a known-groups design to determine optimal cut-off scores for detecting noncredible performance in youths with mild traumatic brain injury (mTBI) across different age-groups. Participants were 114 youths (age 5–17) with mTBI who were referred for neuropsychological evaluation in a hospital-based concussion clinic. All participants were administered the Nonverbal-Medical Symptom Validity Test (NV-MSVT) and the MVP. Participants who failed the NV-MSVT were also administered the TOMM. Participants who failed both the NV-MSVT and the TOMM comprised the criterion group (i.e., the "Failed two PVTs" group). Participants who failed only one PVT were excluded from the analysis. ROC curve analyses revealed good discriminability (AUC =.844: 95%, CI = 676–1.0, p =.001) with acceptable sensitivity (.73) and specificity (.91) for an optimal MVP Total score cut-off ≤31. There were no differences in MVP Total scores across age-groups. In conclusion, adopting stricter cut-points for non-credible performance and applying these consistently across all age groups in a mTBI population increases the clinical utility of the MVP. [ABSTRACT FROM AUTHOR]

Embedded validity measures support comprehensive assessment of performance validity. The purpose of this study was to evaluate the accuracy of individual embedded measures and to reduce them to the most efficient combination. The sample included 212 postdeployment veterans (average age = 35 years, average education = 14 years). Thirty embedded measures were initially identified as predictors of Green’s Word Memory Test (WMT) and were derived from the California Verbal Learning Test-Second Edition (CVLT-II), Conners’ Continuous Performance Test-Second Edition (CPT-II), Trail Making Test, Stroop, Wisconsin Card Sorting Test-64, the Wechsler Adult Intelligence Scale-Third Edition Letter-Number Sequencing, Rey Complex Figure Test (RCFT), Brief Visuospatial Memory Test-Revised, and the Finger Tapping Test. Eight nonoverlapping measures with the highest area-under-the-curve (AUC) values were retained for entry into a logistic regression analysis. Embedded measure accuracy was also compared to cutoffs found in the existing literature. Twenty-one percent of the sample failed the WMT. Previously developed cutoffs for individual measures showed poor sensitivity (SN) in the current sample except for the CPT-II (Total Errors, SN = .41). The CVLT-II (Trials 1–5 Total) showed the best overall accuracy (AUC = .80). After redundant measures were statistically eliminated, the model included the RCFT (Recognition True Positives), CPT-II (Total Errors), and CVLT-II (Trials 1–5 Total) and increased overall accuracy compared with the CVLT-II alone (AUC = .87). The combination of just 3 measures from the CPT-II, CVLT-II, and RCFT was the most accurate/efficient in predicting WMT performance. [ABSTRACT FROM PUBLISHER]

Evaluating performance validity is important in any neuropsychological assessment, and prior research recommends a threshold for invalid performance of two or more performance validity test (PVT) failures. However, extant findings also indicate that failing a single PVT is associated with significant changes in neuropsychological performance. The current study sought to determine if there is an appreciable difference in neuropsychological testing results between individuals failing different numbers of PVTs. In a sample of veterans with reported histories of mild traumatic brain injury (mTBI; N =178), analyses revealed that individuals failing only one PVT performed significantly worse than individuals failing no PVTs on measures of verbal learning and memory, processing speed, and cognitive flexibility. Additionally, individuals failing one versus two PVTs significantly differed only on delayed free recall scores. The current findings suggest that failure of even one PVT should elicit consideration of performance invalidity, particularly in individuals with histories of mTBI. [ABSTRACT FROM PUBLISHER]