The impact of failing to identify suspect effort in patients undergoing adult attention-deficit/hyperactivity disorder (ADHD) assessment.

Abstract

[Correction Notice: An Erratum for this article was reported in Vol 28(10) of (see record 2016-22725-001). In the article, the penultimate sentence of the abstract should read “These results suggest that a significant percentage of those making a suspect effort will be diagnosed with ADHD using the most commonly employed assessment methods: an interview alone (71%); an interview and ADHD behavior rating scales combined (65%); and an interview, behavior rating scales, and most continuous performance tests combined (62%).” All versions of this article have been corrected.] This retrospective study examines how many adult patients would plausibly receive a diagnosis of attention-deficit/hyperactivity disorder (ADHD) if performance and symptom validity measures were not administered during neuropsychological evaluations. Five hundred fifty-four patients were extracted from an archival clinical dataset. A total of 102 were diagnosed with ADHD based on cognitive testing, behavior rating scales, effort testing, and clinical interview; 115 were identified as putting forth suspect effort in accordance with the Slick, Sherman, and Iverson (1999) criteria. From a clinical decision-making perspective, suspect effort and ADHD groups were nearly indistinguishable on ADHD behavior, executive function, and functional impairment rating scales, as well as on cognitive testing and key clinical interview questions. These results suggest that a significant percentage of those making a suspect effort will be diagnosed with ADHD using the most commonly employed assessment methods: an interview alone (71%); an interview and ADHD behavior rating scales combined (65%); and an interview, behavior rating scales, and most continuous performance tests combined (62%) [corrected]. This research makes clear that it is essential to evaluate task engagement and possible symptom amplification during clinical evaluations.

Diagnosing Attention-Deficit/Hyperactivity Disorder (ADHD) in young adults: A qualitative review of the utility of assessment measures and recommendations for improving the diagnostic process

“…Finally, it is important to acknowledge an additional factor when considering the potential diagnostic utility of EF behavior rating scales in diagnosing adult ADHD. Marshall et al (2016) found young adults exaggerating or faking ADHD symptoms were indistinguishable from those diagnosed with ADHD on the two BDEFS indices considered to be most important in making the diagnosis of ADHD: the summary score and total symptom count.…”

“…Pettersson, Soderstrom, and Nilsson (2018) found the aforementioned DIVA had a sensitivity of 90% and specificity of 73%, in a group of adult outpatients presenting for ADHD assessment. Marshall, Hoelzle, Heyerdahl, and Nelson (2016) found that, of 102 patients later diagnosed with ADHD based not only on the interview but additional assessment, 39% had an interview consistent with ADHD, 45% had an indeterminate interview, and 16% had an interview inconsistent with their having this disorder. Those patients with an inconsistent interview but still diagnosed with ADHD had results on multiple behavior rating scales and cognitive tests that provided compelling, substantive evidence of their having ADHD.…”

“…Several studies have documented many adults presenting for ADHD assessment clearly exaggerate or feign cognitive deficits and ADHD symptomatology. Marshall et al (Marshall et al, 2016) found that 27%, Suhr et al (Suhr, Hammers, Dobbins-Buckland, Zimak, & Hughes, 2008) found that 31%, and Nelson and Lovett (2019) found that 53% of young adults undergoing comprehensive ADHD assessment made an invalid symptom presentation. Similarly, in a significantly older adult population, 32% made such an invalid presentation (Hirsch & Christiansen, 2018).…”

“…Further limiting the diagnostic utility of the BFIS and other functional impairment scales is the fact they have no embedded SVTs and can be completed in an invalid manner without detection. Barkley (2011c) has warned that this could happen on the BFIS and Marshall et al (2016) found that this was the case. Bryant et al (2018) had similar findings with respect to the World Health Organization Disability Schedule (WHODAS, World Health Organization, 2012), another commonly used measure of functional impairment.…”

Systematic Review: Nonmedical Use of Prescription Stimulants: Risk Factors, Outcomes, and Risk Reduction Strategies

“…Motivated individuals can fake ADHD by underperforming on psychological measures 112 and overreporting symptoms. 117 Some performance validity tests 110 and symptom validity tests 116 may be reasonably effective at discriminating feigned from genuine ADHD, but this issue has not been adequately investigated to date.…”