Symptom validity assessment is an important part of neuropsychological evaluation. There are currently several free-standing symptom validity tests (SVTs), as well as a number of empirically derived embedded validity indices, that have been developed to assess that an examinee is putting forth an optimal level of effort during testing. The use of embedded validity indices is attractive since they do not increase overall testing time and may also be less vulnerable to coaching. In addition, there are some instances where embedded validity indices are the only tool available to the neuropsychological practitioner for assessing an examinee's level of effort. As with free-standing measures, the sensitivity and specificity of embedded validity indices to suboptimal effort varies. The present study evaluated the diagnostic validity of 17 embedded validity indices by comparing performance on these indices to performance on combinations of free-standing SVTs. Results from the current medico-legal sample revealed that of the embedded validity indices, Reliable Digit Span had the best classification accuracy; however, the findings do not support the use of this embedded validity index in the absence of free-standing SVTs.
There is currently no standard criterion for determining abnormal test scores in neuropsychology; thus, a number of different criteria are commonly used. We investigated base rates of abnormal scores in healthy older adults using raw and T-scores from indices of the Wisconsin Card Sorting Test and Stroop Color-Word Test. Abnormal scores were examined cumulatively at seven cutoffs including >1.0, >1.5, >2.0, >2.5, and >3.0 standard deviations (SD) from the mean as well as those below the 10th and 5th percentiles. In addition, the number of abnormal scores at each of the seven cutoffs was also examined. Results showed when considering raw scores, ∼15% of individuals obtained scores>1.0 SD from the mean, around 10% were less than the 10th percentile, and 5% fell >1.5 SD or <5th percentile from the mean. Using T-scores, approximately 15%-20% and 5%-10% of scores were >1.0 and >1.5 SD from the mean, respectively. Roughly 15% and 5% fell at the <10th and <5th percentiles, respectively. Both raw and T-scores>2.0 SD from the mean were infrequent. Although the presence of a single abnormal score at 1.0 and 1.5 SD from the mean or at the 10th and 5th percentiles was not unusual, the presence of ≥2 abnormal scores using any criteria was uncommon. Consideration of base rate data regarding the percentage of healthy individuals scoring in the abnormal range should help avoid classifying normal variability as neuropsychological impairment.
The determination of examinee effort is an important component of a neuropsychological evaluation and relies heavily on the use of symptom validity tests (SVTs) such as the Test of Memory Malingering (TOMM) and the Word Memory Test (WMT). Diagnostic utility of SVTs varies. The sensitivity of traditional TOMM criteria to suboptimal effort is low. An index of response consistency across three trials of the TOMM was developed, denoted the Albany Consistency Index (ACI). This index identified a large proportion of examinees classified as optimal effort using traditional TOMM interpretive guidelines but suboptimal effort using the WMT profile analysis. In addition, previous research was extended, demonstrating a relationship between examinee performance on SVTs and neuropsychological tests. Effort classification using the ACI predicted the performance on the Global Memory Index from the Memory Assessment Scales. In conclusion, the ACI was a more sensitive indicator of suboptimal effort than traditional TOMM interpretive guidelines.
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