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Objective To cross-validate RAVLT performance validity cut-offs and the RAVLT/RO discriminant function in a large neuropsychological sample. Method RAVLT scores and the RAVLT/RO discriminant function were compared in credible (n = 100) and noncredible (n = 353) neuropsychology referrals. Results Noncredible patients scored lower than credible patients on RAVLT scores and the RAVLT/RO discriminant function. With cut-offs set to ≥90% specificity, highest sensitivities were observed for the discriminant function (cut-off ≤.064; 55.8%), recognition total (cut-off ≤9; 53.1%), the recognition combination score (≤10; 47.7%), and total learning across trials (cut-off ≤31; 45.3%). Individuals with histories of learning difficulties were over-represented in the 10% of credible patients exceeding cut-offs. When these individuals were removed, cut-offs could be tightened while still maintaining at least 90% specificity, and thereby increasing sensitivity (e.g., recognition total cut-off ≤10, 65% sensitivity; RAVLT/RO discriminant function cut-off ≤.176, 58% sensitivity). When three of the most sensitive, non-overlapping scores were considered in combination, 17% of credible patients failed ≥1 of the three cut-offs, while 3% failed two, and only 1% failed all three. In contrast, in the noncredible sample, more than two-thirds failed one or more of the three cut-offs, nearly half failed ≥2, and nearly a quarter failed all three. Conclusions RAVLT PVT cut-offs and the RAVLT/RO discriminant function achieve approximately 50% sensitivity, and approach 65% sensitivity when cut-offs specific to samples without histories of learning problems are employed, confirming that RAVLT cut-offs and the RAVLT/RO discriminant function continue to be valuable techniques in the identification of performance invalidity.

The purpose of the present study was to compare performance on a wide range of PVTs in a neuropsychology clinic sample of African Americans and White Americans to determine if there are differences in mean scores or cut-off failure rates between the two groups, and to identify factors that may account for false positive PVT results in African American patients.African American and White American non-compensation-seeking neuropsychology clinic patients were compared on a wide range of standalone and embedded PVTs: Dot Counting Test, b Test, Warrington Recognition Memory Test, Rey 15-item plus recognition, Rey Word Recognition Test, Digit Span (ACSS, RDS, 3-digit time, 4-digit time), WAIS-III Picture Completion (Most discrepant index), WAIS-III Digit Symbol/Coding (recognition equation), Rey Auditory Verbal Learning Test, Rey Complex figure, WMS-III Logical Memory, Comalli Stroop Test, Trails A, and Wisconsin Card Sorting Test.When groups were equated for age and education, African Americans obtained mean performances significantly worse than White Americans on only four of 25 PVT scores across the 14 different measures (Stroop Word Reading and Color Naming, Trails A, Digit Span 3-digit time); however, FSIQ was also significantly higher in White American patients. When subjects with borderline IQ (FSIQ = 70 to 79) were excluded (resulting in 74 White Americans and 25 African Americans), groups no longer differed in IQ and only continued to differ on a single PVT cutoff (Trails A). Further, specificity rates in African Americans were comparable to those of White Americans with the exception of the b Test, the Dot Counting Test, and Stroop B.PVT performance generally does not differ as a function of Black versus White race once the impact of intellectual level is controlled, and most PVT cutoffs appear appropriate for use in African Americans of low average IQ or higher.

To cross-validate the Dot Counting Test in a large neuropsychological sample.Dot Counting Test scores were compared in credible (n = 142) and non-credible (n = 335) neuropsychology referrals.Non-credible patients scored significantly higher than credible patients on all Dot Counting Test scores. While the original E-score cut-off of ≥17 achieved excellent specificity (96.5%), it was associated with mediocre sensitivity (52.8%). However, the cut-off could be substantially lowered to ≥13.80, while still maintaining adequate specificity (≥90%), and raising sensitivity to 70.0%. Examination of non-credible subgroups revealed that Dot Counting Test sensitivity in feigned mild traumatic brain injury (mTBI) was 55.8%, whereas sensitivity was 90.6% in patients with non-credible cognitive dysfunction in the context of claimed psychosis, and 81.0% in patients with non-credible cognitive performance in depression or severe TBI. Thus, the Dot Counting Test may have a particular role in detection of non-credible cognitive symptoms in claimed psychiatric disorders. Alternative to use of the E-score, failure on ≥1 cut-offs applied to individual Dot Counting Test scores (≥6.0″ for mean grouped dot counting time, ≥10.0″ for mean ungrouped dot counting time, and ≥4 errors), occurred in 11.3% of the credible sample, while nearly two-thirds (63.6%) of the non-credible sample failed one of more of these cut-offs.An E-score cut-off of 13.80, or failure on ≥1 individual score cut-offs, resulted in few false positive identifications in credible patients, and achieved high sensitivity (64.0-70.0%), and therefore appear appropriate for use in identifying neurocognitive performance invalidity.

Introduction Repeated sports-related concussion has been associated with cognitive deficits, like other forms of traumatic brain injury. Football speed players (FSP; e.g., quarterbacks) are at greater risk of cognitive impairment compared to football non-speed players (FNP). Verbal fluency is typically comprised of two tasks: letter fluency (LF) and semantic fluency (SF). Verbal clustering (production of continuous words belonging to the same category or subcategory) and switching (abandoning an exhausted semantic cluster to a new one in order to produce more words) reflect executive control and strategy use. We examined LF, SF, as well as LF and SF switching and clustering performance in retired FSP, FNP, and healthy comparison (HC) participants. Methods The sample consisted of 28 HC, 17 retired FSP, and 53 retired FNP. ANOVAs were conducted to determine group differences on LF, SF, switching, and clustering. FSP and FNP did not differ in concussion frequency. Results We found the HC group outperformed the FSP group in LF, p = 0.042, ηp2 = 0.07. For SF, the HC and FNP groups outperformed the FSP group, p = 0.013, ηp2 = 0.09. Furthermore, we found the HC group outperformed both football groups in SF switching, p = 0.000, ηp2 = 0.17. Conclusion As expected, the HC group outperformed the FSP group on LF and SF. Also, the FNP group outperformed the FSP group on SF. Interestingly, FSP displayed generally worse performances, supporting the notion that their experience of sub-concussive blows puts them at greater risk for cognitive impairment. Further investigation is needed with larger sample sizes to evaluate SF and other cognitive deficits in the FSP participants.

Objective Research shows that traumatic brain injury (TBI) patients perform worse than healthy comparisons (HC) on the Symbol Digit Modalities Test (SDMT). We evaluated cut-off scores for a newly developed recognition trial of the SDMT as a performance validity assessment in monolingual and bilingual TBI survivors and HC adults. Method The sample consisted of 43 acute TBI (ATBI; 24 monolinguals; 19 bilinguals), 32 chronic TBI (CTBI; 13 monolinguals; 19 bilinguals), and 57 HC (24 monolinguals; 33 bilinguals) participants. All participants received standardized administration of the SDMT. None of the participants displayed motivation for feigning cognitive deficits. Results The HC group outperformed both TBI groups on the demographically adjusted SDMT scores, p = 0.000, ηp2 = 0.24. An interaction emerged in SDMT scores where monolingual ATBI outperformed bilingual ATBI and bilingual CTBI outperformed monolingual CTBI, p = 0.017, ηp2 = 0.06. No differences were found in the SDMT recognition trial. Both Bichlmeier and Boone’s suggested cut-off scores had different failure rates in ATBI (Bichlmeier: 77%; Boone: 37%), CTBI (Bichlmeier: 69%; Boone: 19%), and HC (Bichlmeier: 56%; Boone: 26%). For the monolingual group (Bichlmeier: 66%; Boone: 36%) and the bilingual group (Bichlmeier: 66%; Boone: 21%). Finally, chi-squared analysis revealed monolingual TBI had greater failure rates than the bilingual ATBI. Conclusion Bichlmeier’s proposed cut-off score resulted in greater failure rates in TBI survivors compared to Boone’s suggested cut-off score. Furthermore, monolingual ATBI were influenced more by Bichlmeier’s cut-off score than the bilingual ATBI group, although the reason for this finding is unclear and requires additional study with a larger sample size.

Objective Both anxiety and traumatic brain injury (TBI) are both related to poorer Trail Making Test (TMT) performances. TBI survivors exhibit a greater incidence of anxiety in contrast to the general population. We evaluated the relationship between TBI and anxiety on TMT and perceived workload ratings. Method The sample consisted of 39 moderate-to-severe TBI [(21 with normal symptoms of anxiety (NSA) and 18 with abnormal symptoms of anxiety (ASA)] and 51 healthy comparison (HC; 26 NSA and 25 ASA) participants. Results ANCOVA’s, controlling for age, revealed the HC group outperformed the TBI group on TMT part A and TMT part B (TMT-B). An interaction emerged on TMT-B, with TBI-ASA participants outperformed TBI-NSA participants and HC-NSA participants outperformed their counterparts with ASA. Ratings of physical demand and frustration were reported higher in TBI participants compared to the HC participants. Moreover, TBI and anxiety symptoms had interactive effects on NASA-TLX temporal demand and frustration ratings, were TBI-ASA participants reported higher scores in contrast to TBI-NSA. Lastly, an interaction emerged with HC participants with ASA reporting better performances in contrast to HC-NSA. Conclusions As expected, TBI participants did worse on both TMT tasks. Next, we found that TBI-ASA participants impacted their TMT-B performance and their perceived workload (i.e., frustration, temporal demand) more than TBI-NSA participants. In the future, studies with a larger sample size should examine if anxiety influences TMT performance and perceived workload in person with mild TBI.

Introduction We examined the impact of perceived workload and depressive symptoms on Rey-15 plus recognition (RMT) in ethnic minority participants with traumatic brain injury (TBI). Methods The sample consisted of 63 healthy comparison [HC: 38 with ethnic minority status (EM) & 25 non-ethnic minority Caucasian (NEM)] participants and 40 persons with TBI (18 EM; 22 NEM). The Hospital Anxiety and Depression Scale to measure depressive symptoms (HADS-D) and the NASA-Task Load Index (NASA TLX) to measure perceived workload. Results ANCOVAs revealed that NEM outperformed EM on the RMT, p = 0.000, ηp2 = 0.37. TBI survivors reported higher levels of HADS-D compared to HC participants, p = 0.018, ηp2 = 0.06. Additionally, the EM group reported higher levels of frustration on the RMT compared to NEMs, p = 0.033, ηp2 = 0.05. Interactions emerged for physical demand where NEM participant’s with TBI had higher ratings than EM participants with TBI. For HCs, the EM participants provided higher physical demand ratings than their NEM counterparts, p = 0.029, ηp2 = 0.05. Additionally, a significant relationship between HADS-D and RMT was observed in the healthy NEM participants (r = −0.558, p = 0.004) and NEM participants with TBI (r = −0.288, p = 0.080). Finally, significant relationships between HADS-D and mental demand, physical demand, temporal demand, frustration, and overall subjective workload were observed in healthy EM participants, r = 0.342–0.431, p Conclusion Consistent with previous research, TBI survivors reported higher levels of depressive symptoms, which were associated with RMT performances. Overall, our data suggest the relationship between perceived workload, depression, and performance is complex and that investigators should interpret performance validity scores in person with TBI, depression, and/or EM status with great care.

The current study evaluated MSPQ sensitivity to noncredible PVT performance in the context of external incentive, and examined MSPQ false positive rates in noncompensation-seeking neuropsychology patients; and investigated effects of ethnicity/culture, gender, and somatoform diagnosis on MSPQ scores, and relationships with PVT and MMPI-2-RF data.MSPQ scores were compared in credible (n = 110) and noncredible (n = 153) neuropsychology referrals.Noncredible patients scored higher than credible patients. When the credible group was divided into those with somatoform orientation (n = 39) versus those without (n = 71), the credible nonsomatoform group scored lower than the other two groups, who did not differ from each other. MSPQ elevations were found in ethnic minorities, and in individuals who learned English as a second language or concurrently with another language. MSPQ elevations were also associated with chronic systemic diseases, neurologic illness, and substance abuse. Women scored higher than men, but men and women were equally represented among those patients scoring beyond cut-offs. MSPQ scores were minimally related to PVT data but were more strongly correlated with MMPI-2-RF scales, particularly over-report validity scales, RC1, and Somatic/Cognitive scales, with more widespread relationships observed in noncredible patients.A cut-off of 18 resulted in few false positives in credible nonsomatoform patients, and appears appropriate for identifying physical symptom over-report (due to malingering or somatoform orientations), with associated sensitivity of 29%. However, clinicians are cautioned regarding using the MSPQ in patients with systemic, neurologic, and substance abuse conditions, and in ethnic minorities and non-monolingual English-speakers.

Objective Evaluate the effectiveness of Rey 15-item plus recognition data in a large neuropsychological sample. Method Rey 15-item plus recognition scores were compared in credible (n = 138) and noncredible (n = 353) neuropsychology referrals. Results Noncredible patients scored significantly worse than credible patients on all Rey 15-item plus recognition scores. When cut-offs were selected to maintain at least 89.9% specificity, cut-offs could be made more stringent, with the highest sensitivity found for recognition correct (cut-off ≤11; 62.6% sensitivity) and the combination score (recall + recognition – false positives; cut-off ≤22; 60.6% sensitivity), followed by recall correct (cut-off ≤11; 49.3% sensitivity), and recognition false positive errors (≥3; 17.9% sensitivity). A cut-off of ≥4 applied to a summed qualitative error score for the recall trial resulted in 19.4% sensitivity. Approximately 10% of credible subjects failed either recall correct or recognition correct, whereas two-thirds of noncredible patients (67.7%) showed this pattern. Thirteen percent of credible patients failed either recall correct, recognition correct, or the recall qualitative error score, whereas nearly 70% of noncredible patients failed at least one of the three. Some individual qualitative recognition errors had low false positive rates (50) and IQ < 80 were associated with increased false positive rates in credible patients. Conclusions Data on a larger sample than that available in the 2002 validation study show that Rey 15-item plus recognition cut-offs can be made more stringent, and thereby detect up to 70% of noncredible test takers, but the test should be used cautiously in older individuals and in individuals with lowered IQ.

Neuropsychologists use performance validity tests (PVTs; Larrabee, 2012 ) to ensure that results of testing are reflective of the test taker's true neurocognitive ability, and their use is recommended in all compensation-seeking settings. However, whether the type of compensation context (e.g., personal injury litigation versus disability seeking) impacts the nature and extent of neurocognitive symptom feigning has not been adequately investigated. PVT performance was compared in an archival data set of noncredible individuals in either a personal injury litigation (n = 163) or a disability-seeking context (n = 201). Individuals were deemed noncredible based on meeting Slick, Sherman, and Iverson's ( 1999 ) criteria including failure on at least two PVTs and a lack of congruency between their low cognitive scores and normal function in activities of daily living (ADLs). In general, disability seekers tended to perform in a less sophisticated manner than did litigants (i.e., they failed more indicators and did so more extensively). Upon further investigation, these differences were in part accounted for by type of diagnoses feigned; those seeking compensation for mental health diagnoses were more likely to feign or exaggerate a wide variety of cognitive deficits, whereas those with claimed medical diagnoses (i.e., traumatic brain injury) were more targeted in their attempts to feign and/or exaggerate neurocognitive compromise.

The b Test (Boone, Lu,Herzberg, 2002a) is a measure of cognitive performance validity originally validated on 91 non-credible participants and 7 credible clinical comparison groups (total n = 161). The purpose of the current study was to provide cross-validation data for the b Test on a known groups sample of non-credible participants (n = 212) and credible heterogeneous neuropsychological clinic patients (n = 103). The new data showed that while the original E-score cut-off of ≥ 155 achieved excellent specificity (99%), it was associated with relatively poor sensitivity (41%). However, the cut-off could be substantially lowered to ≥82, while still maintaining adequate specificity (≥90%) and raising sensitivity to 68%. Examination of non-credible subgroups revealed that b Test sensitivity in feigned mild traumatic brain injury (mTBI) was 58%, whereas in non-credible patients claiming depression and psychosis, cut-off sensitivity was 76% and 67%, respectively. These data suggest that the b Test may have a particular role in detection of non-credible cognitive symptoms associated with feigned psychiatric symptoms, and that fabricated deficits in processing speed and vigilance/visual scanning, detected by the b Test, are more prominent in feigned psychiatric presentations than in feigned mTBI. Further, b Test failures in patients with somatoform disorders were common, indicating that the b Test may have a specific use in detection of non-consciously created cognitive dysfunction associated with somatoform conditions.

This preliminary study examined the feasibility and potential utility of mindful awareness practices (MAPs) in terms of enhancing student learning in the college classroom, as well as improving psychological well-being. One of two identical undergraduate psychology sections included a 10-minute MAP at the beginning of every class (mindfulness group n = 37; control group n = 23). Primary learning and secondary self-report outcomes were obtained. Controlling for significant demographic covariates, students in the mindfulness group demonstrated significant increases in mindful awareness traits and reductions in rumination and state anxiety compared with controls. While mindfulness intervention did not lead to significant improvement in academic performance across the semester, 81% of students self-reported positive effects of MAPs on their learning. It is concluded that it is feasible to incorporate MAPs into a regular college classroom. MAPs may help improve student psychological well-being. Although students perceived themselves to benefit from their mindfulness practice, further research is needed to examine the effects of MAPs on student academic performance.

The assessment of response validity during neuropsychological evaluation is an integral part of the testing process. Research has increasingly focused on the use of "embedded" effort measures (derived from standard neuropsychological tasks) because they do not require additional administration time and are less likely to be identified as effort indicators by test takers because of their primary focus as measures of cognitive function. The current study examined the clinical utility of various WMS-III Logical Memory scores in detecting response bias, as well as the Rarely Missed Index, an embedded effort indicator derived from the WMS-III Logical Memory Delayed Recognition subtest. The Rarely Missed Index cut-off only identified 24.1% of 63 non-credible participants (at >/=90% specificity in 125 credible patients), and cut-offs for other Logical Memory variables were in fact found to be more sensitive to non-credible performance. A new indicator, consisting of the weighted combination of the two most sensitive Logical Memory subtest scores (Logical Memory II raw score and Logical Memory Delayed Recognition raw score), was associated with 53% to 60% sensitivity, and thus may be an effective adjunct when utilized in conjunction with other validated effort indicators and collateral information in identifying non-credible performance.

Objectives: To examine the role of cognitive impairment and caregiver support in diabetes care adherence and glycemic control. Methods: Fifty-one veteran male outpatients (27 with caregivers) aged 60 years and older with type 2 diabetes were evaluated for cognitive impairment with the Cognitive Abilities Screening Instrument. Patients or caregivers completed diabetes self-care and depression scales. Medical morbidity information and HbA1c plasma levels at baseline and 1 year later were obtained from electronic medical records. Results: Greater cognitive impairment ( F = 5.1, p < .05), and presence of a caregiver ( F = 5.3, p < .05), were independently associated with worse diabetes care adherence (adjusting for age, education, medical comorbidity, and depression). In addition, Mean HbA1c levels were worse in the cognitively impaired group with caregivers relative to the three other groups ( F = 4.10, p < .05, η2 =.09). One year later, mean HbA1c levels rose from 7.7 to 8.2% in the cognitively impaired group with caregivers. Conclusion: Cognitive impairment is associated with worse diabetes care management. Surprisingly, the presence of a caregiver is not protective. Further research is necessary to examine the healthcare needs of cognitively impaired, diabetic patients and their caregivers.

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Fake Bad Scale (FBS; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) has been shown to be sensitive to somatic over-endorsement. However, the impact of ethnicity has not been examined on the FBS, which is of concern given some studies that show increased rates of somatic endorsement in particular ethnic groups. We evaluated the FBS performance of 190 Caucasian American, Hispanic, and African American outpatients who were obtained from two different clinical settings, excluding those who were applying for disability or in litigation. We failed to find significant ethnic differences in mean FBS performance or in cut-off specificity rates. We did find evidence of a gender effect, supporting continued use of gender-specific FBS cutoffs.

The relationship between IQ and nine effort indicators was examined in a sample of 189 neuropsychology clinic outpatients who were not in litigation or attempting to obtain disability. Participants with the lowest IQ (50-59) failed approximately 60% of the effort tests, while patients with an IQ of 60 to 69 failed 44% of effort indicators, and individuals with borderline IQ (70 to 79) exhibited a 17% failure rate. All patients with IQ < 70 failed at least one effort test. Cutoffs for the Warrington Recognition Memory Test (Words) and Finger Tapping maintained the highest specificities in low IQ samples.

The relationship between ethnicity and cognitive test performance was examined in a sample of 161 patients referred for evaluation at a public hospital-affiliated neuropsychology clinic; 83 patients were Caucasian (non-Hispanic), 31 were African-American, 30 were Hispanic, and 17 were Asian. Significant group differences were present on some measures of language (Boston Naming Test), attention (Digit Span ACSS), constructional ability (Rey-Osterrieth [RO] copy), nonverbal processing speed (Trails A), and executive skills (Wisconsin Card Sorting Test [WCST]). Comparison of those who spoke English as a first language (or who learned English concurrently with a second language) versus those who spoke English as a second language (ESL) revealed significantly higher performance in the non-ESL group for Digit Span, Boston Naming Test, and FAS, and a higher score in the ESL group for RO copy. Boston Naming Test scores were significantly related to years educated in the United States; Boston Naming Test and Digit Span scores were significantly correlated with age at which conversational English was first learned and number of years in the United States; and finally, FAS scores were also significantly related to number of years in the United States. These findings are consistent with data from published literature on ethnic differences and the effects of acculturation on cognitive test performance in nonpatients, and also indicate that these observations are not attenuated by the presence of psychiatric or neurologic illness. The results further caution that normative data derived on Caucasian samples may not be appropriate for use with other ethnic groups.

The coaching of clients by attorneys on how to "beat" psychological tests in the context of personal injury or disability litigation poses a serious concern for the practice of psychological assessment. This article reviews the empirical literature with respect to the effects of coaching on psychological tests, discusses current ethical and legal standards relevant to coaching on psychological tests, and offers suggestions on how the field of assessment psychology might deal with this challenge. This review has important implications for all clinicians conducting psychological and neuropsychological assessments in forensic settings.

Older adults are the fastest growing subpopulation in the United States, and it is likely that the demand for well-trained clinical geropsychologists will expand. This trend has important implications for research and graduate training. One promising area of research concerns the most effective ways of dealing with long-term illness in partners of older adults. With regard to training, we point out that the connection between neuropsychology and geropsychology needs further emphasis. Increasing the number of geropsychology programs is clearly desirable, and further funding to support and increase the number of such programs should be of high priority. Two recent developments are also highlighted. The first involves a federal court case that addresses the relationship between physical and mental illness, an issue particularly important to mental health parity concerning insurance reimbursements. The second issue concerns prescription privileges for psychologists in view of the recently passed law in New Mexico permitting psychologists to prescribe medicine. This article discusses the implications of these developments.

The purpose of this archival study was to identify performance validity tests (PVTs) and standard IQ and neurocognitive test scores, which singly or in combination, differentiate credible patients of low IQ (FSIQ ≤ 75; n = 55) from non-credible patients. We compared the credible participants against a sample of 74 non-credible patients who appeared to have been attempting to feign low intelligence specifically (FSIQ ≤ 75), as well as a larger non-credible sample (n = 383) unselected for IQ. The entire non-credible group scored significantly higher than the credible participants on measures of verbal crystallized intelligence/semantic memory and manipulation of overlearned information, while the credible group performed significantly better on many processing speed and memory tests. Additionally, credible women showed faster finger-tapping speeds than non-credible women. The credible group also scored significantly higher than the non-credible subgroup with low IQ scores on measures of attention, visual perceptual/spatial tasks, processing speed, verbal learning/list learning, and visual memory, and credible women continued to outperform non-credible women on finger tapping. When cut-offs were selected to maintain approximately 90% specificity in the credible group, sensitivity rates were highest for verbal and visual memory measures (i.e., TOMM trials 1 and 2; Warrington Words correct and time; Rey Word Recognition Test total; RAVLT Effort Equation, Trial 5, total across learning trials, short delay, recognition, and RAVLT/RO discriminant function; and Digit Symbol recognition), followed by select attentional PVT scores (i.e., b Test omissions and time to recite four digits forward). When failure rates were tabulated across seven most sensitive scores, a cut-off of ≥ 2 failures was associated with 85.4% specificity and 85.7% sensitivity, while a cut-off of ≥ 3 failures resulted in 95.1% specificity and 66.0% sensitivity. Results are discussed in light of extant literature and directions for future research.

Practice guidelines recommend the use of multiple performance validity tests (PVTs) to detect noncredible performance during neuropsychological evaluations, and PVTs embedded in standard cognitive tests achieve this goal most efficiently. The present study examined the utility of the Comalli version of the Stroop Test as a measure of response bias in a large sample of "real world" noncredible patients (n = 129) as compared with credible neuropsychology clinic patients (n=233). The credible group performed significantly better than the noncredible group on all trials, but particularly on word-reading (Stroop A) and color-naming (Stroop B); cut-scores for Stroop A and Stroop B trials were associated with moderate sensitivity (49-53%) as compared to the low sensitivity found for the color interference trial (29%). Some types of diagnoses (including learning disability, severe traumatic brain injury, psychosis, and depression), very advanced age (⩾80), and lowered IQ were associated with increased rates of false positive identifications, suggesting the need for some adjustments to cut-offs in these subgroups. Despite some previous reports of an inverted Stroop effect (i.e., color-naming worse than color interference) in noncredible subjects, individual Stroop word reading and color naming trials were much more effective in identifying response bias.

A Rey-Osterrieth Complex Figure Test (ROCFT) equation incorporating copy and recognition was found to be useful in detecting negative response bias in neuropsychological assessments (ROCFT Effort Equation; Lu, P. H., Boone, K. B., Cozolino, L., & Mitchell, C. (2003). Effectiveness of the Rey-Osterrieth Complex Figure Test and the Meyers and Meyers recognition trial in the detection of suspect effort. Clinical Neuropsychologist, 17, 426-440). In the current cross validation of this validity, the credible patient group (n = 146; 124 with equation data) outperformed the noncredible group (n = 157; 115 with equation data) on copy, 3-min recall, total recognition correct and the Effort Equation, but the latter was most effective in classifying subjects. A cut-off of ≤50 maintained specificity of 90% and achieved sensitivity of 80%. Results of the current cross validation provide corroboration that the ROCFT Effort Equation is an effective measure of neurocognitive response bias.

The Rey Word Recognition Test, a brief and simple to administer free-standing neurocognitive performance validity test, was examined in a large known-groups sample (122 credible patients and 134 non-credible patients). Total correctly recognized was the most sensitive score, identifying 54% of non-credible participants using a cut-off of ≤6, while maintaining specificity of approximately 90%. However, specifically rates were somewhat lower in credible individuals with

In the present study a large sample of credible patients (n = 172) scored significantly higher than a large sample of noncredible participants (n = 195) on several WAIS-III Picture Completion variables: Age Adjusted Scaled Score, raw score, a "Rarely Missed" index (the nine items least often missed by credible participants), a "Rarely Correct" index (nine items correct

Recently published practice standards recommend that multiple effort indicators be interspersed throughout neuropsychological evaluations to assess for response bias, which is most efficiently accomplished through use of effort indicators from standard cognitive tests already included in test batteries. The present study examined the utility of a timed recognition trial added to standard administration of the WAIS-III Digit Symbol subtest in a large sample of "real world" noncredible patients (n=82) as compared with credible neuropsychology clinic patients (n=89). Scores from the recognition trial were more sensitive in identifying poor effort than were standard Digit Symbol scores, and use of an equation incorporating Digit Symbol Age~Corrected Scaled Scores plus accuracy and time scores from the recognition trial was associated with nearly 80% sensitivity at 88.7% specificity. Thus, inclusion of a brief recognition trial to Digit Symbol administration has the potential to provide accurate assessment of response bias.

Several studies have examined the usefulness of the Warrington Recognition Memory Test-Words as a measure to detect suspect effort, although samples have generally been small and/or comprised of simulators rather than "real world" credible and noncredible patients. The current study examined the Warrington Recognition Memory Test-Words total score and response time of "real world" noncredible patients (as determined by motive to feign, failure onor =2 independent measures of response bias, low cognitive scores inconsistent with normal ADLs; n = 190) versus credible patients (as determined by no motive to feign, failure ofor =1 measure of response bias; n = 124) derived from an archival database of individuals from the Harbor-UCLA Medical Center, Department of Psychiatry, Outpatient Neuropsychology Service, and the private practice of the second author. Noncredible patients obtained significantly lower total scores and longer times to complete the task. A total correct cutoff ofor =42 was found to have excellent specificity (91.9%) and sensitivity (88.9%), whereas a time cutoff ofor =207'' was associated with 65.5% sensitivity at 90.7% specificity, and when the time cut-score was used in combination with the total score cutoff, an additional 5% of the noncredible participants were captured, raising overall sensitivity to 93.7% (at 87.1% specificity). Thus, the Warrington Recognition Memory Test-Words, although not originally created for the purposes of measuring suspect effort, appears to be an excellent measure for detecting response bias on neuropsychological testing.

While it is recommended that judgments regarding the credibility of test performance be based on the results of more than one effort indicator, and recent efforts have been made to improve interpretation of multiple effort test failure, the field currently lacks adequate guidelines for using multiple measures of effort in concert with one another. A total of 103 patients were referred for outpatient neuropsychological evaluation, which included multiple measures of negative response bias embedded in standard test batteries. Using any pairwise failure combination to predict diagnostic classification was superior (sensitivity = 83.8%, specificity = 93.9%, overall hit rate = 90.3%) to using any one test by itself and to using any three-test failure combination. Further, the results were comparable to the results of logistical regression analyses using the embedded indicators as continuous predictors. Given its parsimony and clinical utility, the pairwise failure model is therefore a recommended criterion for identifying non-credible performance; however, there are of course other important contextual factors and influences to consider, which are also discussed.

Research on the performance of patients with dementia on tests of effort is particularly limited. We examined archival data from 214 non-litigating patients with dementia on 18 effort indices derived from 12 tests (WAIS-III/WAIS-R Digit Span and Vocabulary, Dot Counting Test, Warrington Recognition Memory Test-Words, WMS-III Logical Memory, Rey Word Recognition Memory Test, Finger Tapping, b-Test, Rey 15-Item, Test of Memory Malingering, Rey Auditory Verbal Learning Test, and Rey Complex Figure Test). Results indicated that recommended cut-offs for Digit Span indicators (Vocabulary Minus Digit Span and four-digit forward span time score) provided > or =90% specificity across participants, while the majority of other effort tests displayed specificities in the 30-70% range. Analyses of test specificity as a function of Mini Mental Status Examination (MMSE) score and specific dementia diagnosis are provided, as well as adjustments to cut-offs to maintain specificity where feasible.