White Matter Hyperintensities Are Not Related to Symptomatology or Cognitive Functioning in Service Members with a Remote History of Traumatic Brain Injury

This study aimed to determine whether magnetic resonance imaging (MRI) white matter hyperintensities (WMHs) are associated with symptom reporting and/or cognitive performance in 1202 active-duty service members with prior single or multiple mild traumatic brain injury (mTBI). Patients with mTBI evaluated at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC) were divided into those with (n = 632) and without (n = 570) WMHs. The groups were compared on several self-report scales including the Neurobehavioral Symptom Inventory (NSI), Post-Traumatic Stress Disorder (PTSD) Checklist-Civilian Version (PCL-C), Satisfaction with Life Scale (SWLS), and Short Form-36 Health Survey (SF-36). They were also compared on several neuropsychological measures, including tests of attention, working memory, learning and memory, executive functioning, and psychomotor functioning. After correction for multiple comparisons, there were no significant differences between the two groups on any self-reported symptom scale or cognitive test. When comparing a subgroup with the highest (20+) WMH burden (n = 60) with those with no WMHs (n = 60; matched on age, education, sex, race, rank, and TBI number), only SF-36 Health Change significantly differed between the subgroups; the multiple WMH subgroup reported worsening health over the past year (t[53] = 3.52, p = 0.001, d = 0.67) compared with the no WMH subgroup. These findings build on prior research suggesting total WMHs are not associated with significant changes in self-reported symptoms or cognitive performance in patients with a remote history of mTBI. As such, clinicians are encouraged to use caution when reporting such imaging findings.

The Impact of Learning and Memory on Performance Validity Tests in a Mixed Clinical Pediatric Population

OBJECTIVE

This study examined the degree to which verbal and visuospatial memory abilities influence performance validity test (PVT) performance in a mixed clinical pediatric sample.

METHOD

Data from 252 consecutive clinical pediatric cases (Mage=11.23 years, SD=4.02; 61.9% male) seen for outpatient neuropsychological assessment were collected. Measures of learning and memory (e.g., The California Verbal Learning Test-Children's Version; Child and Adolescent Memory Profile [ChAMP]), performance validity (Test of Memory Malingering Trial 1 [TOMM T1]; Wechsler Intelligence Scale for Children-Fifth Edition [WISC-V] or Wechsler Adult Intelligence Scale-Fourth Edition Digit Span indices; ChAMP Overall Validity Index), and intellectual abilities (e.g., WISC-V) were included.

RESULTS

Learning/memory abilities were not significantly correlated with TOMM T1 and accounted for relatively little variance in overall TOMM T1 performance (i.e., ≤6%). Conversely, ChAMP Validity Index scores were significantly correlated with verbal and visual learning/memory abilities, and learning/memory accounted for significant variance in PVT performance (12%-26%). Verbal learning/memory performance accounted for 5%-16% of the variance across the Digit Span PVTs. No significant differences in TOMM T1 and Digit Span PVT scores emerged between verbal/visual learning/memory impairment groups. ChAMP validity scores were lower for the visual learning/memory impairment group relative to the nonimpaired group.

CONCLUSIONS

Findings highlight the utility of including PVTs as standard practice for pediatric populations, particularly when memory is a concern. Consistent with the adult literature, TOMM T1 outperformed other PVTs in its utility even among the diverse clinical sample with/without learning/memory impairment. In contrast, use of Digit Span indices appear to be best suited in the presence of visuospatial (but not verbal) learning/memory concerns. Finally, the ChAMP's embedded validity measure was most strongly impacted by learning/memory performance.

Examining Traditional and Novel Validity Indicators from the Medical Symptom Validity Test Across Levels of Verbal and Visual Memory Impairment

OBJECTIVE

This cross-sectional study examined accuracy of traditional Medical Symptom Validity Test (MSVT) validity indicators, including immediate recognition (IR), delayed recognition (DR), and consistency (CNS), as well as a novel indicator derived from the mean performance on IR, DR, and CNS across verbal, visual, and combined learning and memory impairment bands.

METHOD

A sample of 180 adult outpatients was divided into valid (n = 150) and invalid (n = 30) groups based on results of four independent criterion performance validity tests. Verbal and visual learning and recall were classified as indicative of no impairment, mild impairment, or severe impairment based on performance on the Rey Auditory Verbal Learning Test and Brief Visuospatial Memory Test-Revised, respectively.

RESULTS

In general, individual MSVT subtests were able to accurately classify performance as valid or invalid, even in the context of severe learning and memory deficits. However, as verbal and visual memory impairment increased, optimal MSVT cut-scores diverged from manual-specified cutoffs such that DR and CNS required cut-scores to be lowered to maintain adequate specificity. By contrast, the newly proposed scoring algorithm generally showed more robust psychometric properties across the memory impairment bands.

CONCLUSIONS

The mean performance index, a novel scoring algorithm using the mean of the three primary MSVT subtests, may be a more robust validity indicator than the individual MSVT subtests in the context of bona fide memory impairment.

Flipping the Script: Measuring Both Performance Validity and Cognitive Ability with the Forced Choice Recognition Trial of the RCFT

In this study we attempted to replicate the classification accuracy of the newly introduced Forced Choice Recognition trial (FCR) of the Rey Complex Figure Test (RCFT) in a clinical sample. We administered the RCFT_FCR and the earlier Yes/No Recognition trial from the RCFT to 52 clinically referred patients as part of a comprehensive neuropsychological test battery and incentivized a separate control group of 83 university students to perform well on these measures. We then computed the classification accuracies of both measures against criterion performance validity tests (PVTs) and compared results between the two samples. At previously published validity cutoffs (≤16 & ≤17), the RCFT_FCR remained specific (.84-1.00) to psychometrically defined non-credible responding. Simultaneously, the RCFT_FCR was more sensitive to examinees' natural variability in visual-perceptual and verbal memory skills than the Yes/No Recognition trial. Even after being reduced to a seven-point scale (18-24) by the validity cutoffs, both RCFT recognition scores continued to provide clinically useful information on visual memory. This is the first study to validate the RCFT_FCR as a PVT in a clinical sample. Our data also support its use for measuring cognitive ability. Replication studies with more diverse samples and different criterion measures are still needed before large-scale clinical application of this scale.

Association of Previous Concussion with Hippocampal Volume and Symptoms in Collegiate-Aged Athletes

There is concern that previous concussion and contact-sport exposure may have negative effects on brain structure and function. Accurately quantifying previous concussion is complicated by the fact that multiple definitions exist, with recent definitions allowing for diagnosis based on the presence of symptoms alone (Concussion in Sport Group criteria; CISG) rather than the presence of acute injury characteristics such as alterations in mental status (American Congress of Rehabilitation Medicine criteria; ACRM). The goals of the current work were to determine the effects of previous concussion and contact-sport exposure on gray matter structure and clinical measures in healthy, young-adult athletes and determine the extent to which these associations are influenced by diagnostic criteria used to retrospectively quantify concussions. One-hundred eight collegiate-aged athletes were enrolled; 106 athletes were included in final analyses (age, 21.37 ± 1.69; 33 female). Participants completed a clinical battery of self-report and neurocognitive measures and magnetic resonance imaging to quantify subcortical volumes and cortical thickness. Semistructured interviews were conducted to measure exposure to contact sports and the number of previous concussions based on CISG and ACRM criteria. There was a significant association of concussion-related and psychological symptoms with previous concussions based on ACRM (ps < 0.05), but not CISG, criteria. Hippocampal volume was inversely associated with the number of previous concussions for both criteria (ps < 0.05). Findings provide evidence that previous concussions are associated with smaller hippocampal volumes and greater subjective clinical symptoms in otherwise healthy athletes and highlight the importance of diagnostic criteria used to quantify previous concussion.

The Development and Validation of the Embedded Validity Indicator for the Neuropsychological Assessment Battery

OBJECTIVE

The purpose of this study was to develop and validate an embedded measure of performance validity within the Neuropsychological Assessment Battery (NAB).

METHOD

This study involved a retrospective chart review at an outpatient neuropsychology clinic. Participants were 183 adults (ages 18-70) who completed the attention and memory modules of the NAB, as well as the Word Choice Test, Green's Medical Symptom Validity Test (MSVT), and Green's Non-Verbal MSVT, as part of a clinical neuropsychological assessment (n = 147) or as part of a forensic neuropsychological evaluation (n = 36). Replicating methodology utilized by Silverberg et al. (2007) for the development of the Effort Index within the Repeatable Battery for the Assessment of Neuropsychological Status, an Embedded Validity Indictor (EVI) for the NAB was developed in the present study based on Digits Forward and List Learning Long Delayed Forced-Choice Recognition (list recognition) subtests.

RESULTS

Receiver operating characteristic curve analyses indicated the newly developed NAB EVI was able to significantly differentiate between valid and invalid status on stand-alone performance-validity tests, with area under the curve values ranging from 0.797 to 0.977. Optimal cutoffs for medical, forensic, and mixed samples were identified.

CONCLUSIONS

The newly developed NAB EVI shows promise as an embedded performance validity measure; however, due to moderate sensitivity, it should be used in combination with stand-alone performance validity tests to detect invalid performance.

The relationship between neuropsychological dispersion, processing speed and memory after electrical injury

Introduction: Previous studies of neuropsychological performance in electrical injury (EI) patients have produced evidence of deficits in various cognitive domains, but studies have yet to investigate relationships among performance in cognitive domains post-EI. This study examined whether dispersion among neuropsychological test scores was associated with injury parameters and neuropsychological performance in EI patients. Additionally, we examined whether dispersion, processing speed and/or executive abilities explain variance in episodic verbal and visual memory performance among EI patients.Method: Data from 52 post-acute EI patients undergoing outpatient evaluation with objectively-verified valid neuropsychological test performance were examined. Tests included measures of verbal and visual memory, processing speed, and executive functioning. Dispersion was calculated from executive functioning and processing speed scores.Results: Dispersion was not related to mean performance or injury characteristics, but was significantly negatively correlated with performance on a test of processing speed, suggesting that increased dispersion is associated with reduced cognitive efficiency post-EI. Delayed visual memory was related to both dispersion scores and processing speed. Stepwise regression equations predicting delayed memory determined that processing speed most significantly predicted delayed visual memory, even after controlling for immediate visual memory. No significant relationships emerged between verbal memory and non-memory neuropsychological scores.Conclusions: This is the first study to examine neuropsychological dispersion and relationships among domains of cognitive functioning in EI. Current results suggested that neuropsychological dispersion is not a marker of general functioning or severity of injury in EI patients, but may represent more specific processing speed abilities. Processing speed predicts delayed visual memory performance in EI patients, which should be considered in interpreting test scores during evaluations.

Mean response latency indices on the Victoria Symptom Validity Test do not contribute meaningful predictive value over accuracy scores for detecting invalid performance

The utility of the Victoria Symptom Validity Test (VSVT) as a performance validity test (PVT) has been primarily established using response accuracy scores. However, the degree to which response latency may contribute to accurate classification of performance invalidity over and above accuracy scores remains understudied. Therefore, this study investigated whether combining VSVT accuracy and response latency scores would increase predictive utility beyond use of accuracy scores alone. Data from a mixed clinical sample of 163 patients, who were administered the VSVT as part of a larger neuropsychological battery, were analyzed. At least four independent criterion PVTs were used to establish validity groups (121 valid/42 invalid). Logistic regression models examining each difficulty level revealed that all VSVT measures were useful in classifying validity groups, both independently and when combined. Individual predictor classification accuracy ranged from 77.9 to 81.6%, indicating acceptable to excellent discriminability across the validity indices. The results of this study support the value of both accuracy and latency scores on the VSVT to identify performance invalidity, although the accuracy scores had superior classification statistics compared to response latency, and mean latency indices provided no unique benefit for classification accuracy beyond dimensional accuracy scores alone.

Victoria Symptom Validity Test: A Systematic Review and Cross-Validation Study

The Victoria Symptom Validity Test (VSVT) is a performance validity test (PVT) with over two decades of empirical backing, although methodological limitations within the extant literature restrict its clinical and research generalizability. Chief among these constraints includes limited consensus on the most accurate index within the VSVT and the most appropriate cut-scores within each VSVT validity index. The current systematic review synthesizes existing VSVT validation studies and provides additional cross-validation in an independent sample using a known-groups design. We completed a systematic search of the literature, identifying 17 peer-reviewed studies for synthesis (7 simulation designs, 7 differential prevalence designs, and 3 known-groups designs). The independent cross-validation sample consisted of 200 mixed clinical neuropsychiatric patients referred for outpatient neuropsychological evaluation. Across all indices, Total item accuracy produced the strongest psychometric properties at an optimal cut-score of ≤ 40 (62% sensitivity/88% specificity). However, ROC curve analyses for all VSVT indices yielded statistically significant areas under the curve (AUCs; .73-81), suggestive of moderate classification accuracy. Cut-scores derived using the independent cross-validation sample converged with some previous findings supporting cut-scores of ≤ 22 for Easy item accuracy and ≤ 40 for Total item accuracy, although divergent findings were noted for Difficult item accuracy. Overall, VSVT validity indicators have adequate diagnostic accuracy across populations, with the current study providing additional support for its use as a psychometrically sound PVT in clinical settings. However, caution is recommended among patients with certain verified clinical conditions (e.g., dementia) and those with pronounced working memory deficits due to concerns for increased risk of false positives.

A Known-Groups Validation of the Medical Symptom Validity Test and Analysis of the Genuine Memory Impairment Profile

This study cross-validated the Medical Symptom Validity Test (MSVT) in a mixed neuropsychiatric sample and examined its accuracy for identifying invalid neuropsychological performance using a known-groups design. Cross-sectional data from 129 clinical patients who completed the MSVT were examined. Validity groups were established using six, independent criterion performance validity tests, which yielded 98 patients in the valid group and 31 in the invalid group. All MSVT subtest scores were significantly lower in the invalid group (η p2=.22-.39). Using published cut-scores, sensitivities of 42% to 71% were found among the primary effort subtests, and 74% sensitivity/90% specificity was observed for the overall MSVT. Among this sample, the MSVT component validity scales produced areas under the curve of .78-.86, suggesting moderate classification accuracy. At optimal cut-scores, the MSVT primary effort validity scales demonstrated 55% to 71% sensitivity/91% to 93% specificity, with the Consistency subtest exhibiting the strongest psychometric properties. The MSVT exhibited relatively robust sensitivity and specificity, supporting its utility as a briefer freestanding performance validity test to its predecessor, the Word Memory Test. Finally, the Genuine Memory Impairment Profile appears promising for patients with Major Neurocognitive Disorder, but is cautioned against for those without significant functional decline in activities of daily living at this time.

Resting-State Power and Regional Connectivity After Pediatric Mild Traumatic Brain Injury

BACKGROUND

Physiological recovery from pediatric mild traumatic brain injury (pmTBI) as a function of age remains actively debated, with the majority of studies relying on subjective symptom report rather than objective markers of brain physiology.

PURPOSE

To examine potential abnormalities in fractional amplitude of low-frequency fluctuations (fALFF) or regional homogeniety (ReHo) during resting-state fMRI following pmTBI.

STUDY TYPE

Prospective cohort.

POPULATION

Consecutively recruited pmTBI (N = 105; 8-18 years old) and age- and sex-matched healthy controls (HC; N = 113).

FIELD STRENGTH/SEQUENCE

3T multiecho gradient T1 -weighted and single-shot gradient-echo echo-planar imaging.

ASSESSMENT

All pmTBI participants were assessed 1 week and 4 months postinjury (HC assessed at equivalent timepoints after the first visit). Comprehensive demographic, clinical, and cognitive batteries were performed in addition to primary investigation of fALFF and ReHo. All pmTBI were classified as "persistent" or "recovered" based on both assessment periods.

STATISTICAL TESTS

Chi-square, nonparametric, and generalized linear models for demographic data. Generalized estimating equations for clinical and cognitive data. Voxelwise general linear models (AFNI's 3dMVM) for fALFF and ReHo assessment.

RESULTS

Evidence of recovery was observed for some, but not all, clinical and cognitive measures at 4 months postinjury. fALFF was increased in the left striatum for pmTBI relative to HC both at 1 week and 4 months postinjury; whereas no significant group differences (P > 0.001) were observed for ReHo. Age-at-injury did not moderate either resting-state metric across groups. In contrast to analyses of pmTBI as a whole, there were no significant (P > 0.001) differences in either fALFF or ReHo in patients with persistent postconcussive symptoms compared to recovered patients and controls at 4 months postinjury.

DATA CONCLUSIONS

Our findings suggest prolonged clinical recovery and alterations in the relative amplitude of resting-state fluctuations up to 4 months postinjury, but no clear relationship with age-at-injury or subjective symptom report.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: 2 J. MAGN. RESON. IMAGING 2020;52:1701-1713.

Clinical utility of the TOMMe10 scoring criteria for detecting suboptimal effort in an mTBI veteran sample

In the context of diminishing reimbursement and patient access demands, researchers continually refine performance validity measures (PVMs) to maximize efficiency while maintaining confidence in obtained data. This is particularly true for high PVM failure populations (e.g., mTBI patients). The TOMMe10 (number of errors on first 10 TOMM items) is one method this study utilized for classifying PVM performance as pass/fail (fail defined as failure on 2 of 6 PVM scores, pass defined as 0/1 failures). The present study hypothesized that the TOMMe10 would have equitable sensitivity/specificity for identifying non-credible cognitive performance among veterans with mTBI compared to previous research findings and commonly used performance validity measures (e.g., TOMM or WMT). Data were analyzed from 54 veterans assigned to a pass and fail group based on their performance across six recognized PVMs. Results revealed pass/fail groups were not significantly different regarding age, educational, or racial background. ROC analyses found the TOMMe10 demonstrated excellent discriminability (AUC = .803 ±.128), indicating that the TOMMe10 could have clinical utility within an mTBI veteran sample, particularly in conjunction with a second PVM. Specific population limitations are discussed. Additional research should elucidate this measure's performance with additional populations, including non-veteran mTBI, dementia, moderate-severe TBI, and inpatient populations.

Early Cutoff Criteria for Strong Performance on the Test of Memory Malingering

OBJECTIVE

The Test of Memory Malingering (TOMM) is widely used to assess performance validity. To improve efficiency, we investigated whether abbreviated administration (i.e., only the first 25 items of Trial 1 [T1]) is possible when effort is very strong (≥49/50 on T1 or T2).

METHOD

We collected TOMM scores of 501 consecutive adult patients ranging in cognitive status who underwent standard neuropsychological evaluation at Mayo Clinic, Rochester, MN.

RESULTS

Receiver Operating Characteristic (ROC) analysis showed excellent area under the curve (AUC) (0.94; CI95% [0.92, 0.97]) and a cutoff of 25/25 had 100% specificity for identifying strong performance. Of the 224 patients who obtained a perfect score on the first 25 items, 197 (88%) obtained ≥49 on T1 and the remaining patients (n = 27) obtained ≥49 on T2.

CONCLUSION

A perfect score on the first 25 items of the TOMM predicted overall strong performance 100% of the time, supporting abbreviated administration in select cases in a general outpatient clinical setting.

United States Military Service Members Demonstrate Substantial and Heterogeneous Long-Term Neuropsychological Dysfunction after Moderate, Severe, and Penetrating Traumatic Brain Injury

The objective of the study was to examine long-term neuropsychological outcome after moderate, severe, and penetrating traumatic brain injury (TBI) in U.S. military service members and veterans (SMVs). Eighty-five SMVs with a history of moderate (n = 18), severe (n = 17), or penetrating (n = 26) TBI, or an injury without TBI (i.e., trauma control [TC], n = 24) were assessed five or more years (mean = 69.4 months; standard deviation = 35.6) post-injury. All passed performance validity tests. Participants completed a battery of neurocognitive tests and a personality inventory. Five cognitive domain composites, each composed of four test scores, and an overall test battery mean (OTBM) were computed. The penetrating TBI group performed worse than the TC group and/or the moderate TBI group on most cognitive domains and the OTBM. The severe TBI group also performed worse than the TC group and moderate TBI group on processing speed and the OTBM, and worse than the TC group on attention/working memory. Just more than half of participants with severe (56%) or penetrating (64%) TBI met criteria for mild neurocognitive disorder, with processing speed the most commonly impaired domain. In addition, 80% of TBI participants had one or more clinically elevated scales on the Minnesota Multiphasic Personality Inventory-2-Restructured Form^® (MMPI-2-RF), with somatic complaints the most common elevation. In conclusion, there was significantly reduced cognitive and psychological functioning many years after severe and penetrating TBI in SMVs. Cognitive and psychological dysfunction, however, were highly variable, with a substantial minority of SMVs having good outcome. Long-term individualized support is necessary for individuals after moderate, severe, and penetrating TBI.

Neurocognitive markers of childhood abuse in individuals with PTSD: Findings from the INTRuST Clinical Consortium

To date, few studies have evaluated the contribution of early life experiences to neurocognitive abnormalities observed in posttraumatic stress disorder (PTSD). Childhood maltreatment is common among individuals with PTSD and is thought to catalyze stress-related biobehavioral changes that might impact both brain structure and function in adulthood. The current study examined differences in brain morphology (brain volume, cortical thickness) and neuropsychological performance in individuals with PTSD characterized by low or high self-reported childhood maltreatment, compared with healthy comparison participants. Data were drawn from the INjury and TRaUmatic STress (INTRuST) Clinical Consortium imaging repository, which contains MRI and self-report data for individuals classified as PTSD positive (with and without a history of mild traumatic brain injury [mTBI]), individuals with mTBI only, and healthy comparison participants. The final sample included 36 individuals with PTSD without childhood maltreatment exposure (PTSD, n = 30 with mTBI), 31 individuals with PTSD and childhood maltreatment exposure (PTSD + M, n = 26 with mTBI), and 114 healthy comparison participants without history of childhood maltreatment exposure (HC). The PTSD + M and PTSD groups demonstrated cortical thinning in prefrontal and occipital regions, and poorer verbal memory and processing speed compared to the HC group. PTSD + M participants demonstrated cortical thinning in frontal and cingulate regions, and poorer executive functioning relative to the PTSD and HC groups. Thus, neurocognitive features varied between individuals with PTSD who did versus did not have exposure to childhood maltreatment, highlighting the need to assess developmental history of maltreatment when examining biomarkers in PTSD.

Psychological Symptoms and Rates of Performance Validity Improve Following Trauma-Focused Treatment in Veterans with PTSD and History of Mild-to-Moderate TBI

OBJECTIVE

Iraq and Afghanistan Veterans with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) history have high rates of performance validity test (PVT) failure. The study aimed to determine whether those with scores in the invalid versus valid range on PVTs show similar benefit from psychotherapy and if psychotherapy improves PVT performance.

METHOD

Veterans (N = 100) with PTSD, mild-to-moderate TBI history, and cognitive complaints underwent neuropsychological testing at baseline, post-treatment, and 3-month post-treatment. Veterans were randomly assigned to cognitive processing therapy (CPT) or a novel hybrid intervention integrating CPT with TBI psychoeducation and cognitive rehabilitation strategies from Cognitive Symptom Management and Rehabilitation Therapy (CogSMART). Performance below standard cutoffs on any PVT trial across three different PVT measures was considered invalid (PVT-Fail), whereas performance above cutoffs on all measures was considered valid (PVT-Pass).

RESULTS

Although both PVT groups exhibited clinically significant improvement in PTSD symptoms, the PVT-Pass group demonstrated greater symptom reduction than the PVT-Fail group. Measures of post-concussive and depressive symptoms improved to a similar degree across groups. Treatment condition did not moderate these results. Rate of valid test performance increased from baseline to follow-up across conditions, with a stronger effect in the SMART-CPT compared to CPT condition.

CONCLUSION

Both PVT groups experienced improved psychological symptoms following treatment. Veterans who failed PVTs at baseline demonstrated better test engagement following treatment, resulting in higher rates of valid PVTs at follow-up. Veterans with invalid PVTs should be enrolled in trauma-focused treatment and may benefit from neuropsychological assessment after, rather than before, treatment.

Relative impacts of mild and major neurocognitive disorder on rate of verbal learning acquisition

OBJECTIVE

The California Verbal Learning Test-second edition (CVLT-II) learning slope index may signal the presence of cognitive impairment, though the relative impacts of mild (MiND) and major (MaND) neurocognitive disorders on the rate of verbal learning acquisition remain unknown.

METHODS

Latent intercept-only, linear, quadratic, and exponential models were fit to raw scores for the five CVLT-II learning trials of 197 veterans. Dummy-coded variables reflecting MiND and MaND predicted the growth factors.

RESULTS

Quadratic growth best fit the data. MiND and MaND predicted reduced recall on each trial. MaND predicted reduced rate of learning acquisition (i.e., word gains per trial) over-and-above MiND, even after controlling for age, sex, education, race/ethnicity, and mono/bilingualism.

CONCLUSIONS

Nonlinear growth-with continuous but diminishing gains over trials-best characterized verbal learning acquisition. Reduced word recall each trial may help differentiate MiND from no neurocognitive disorder, while reduced rate of verbal learning acquisition may help differentiate MaND from MiND.

The validity of the test of memory malingering (TOMM) with deaf individuals

OBJECTIVE

Administration of performance validity tests (PVT) during neuropsychological assessments is standard practice, with the Test of Memory Malingering (TOMM) being a commonly used measure. The TOMM has been well validated in hearing populations with various medical and psychiatric backgrounds. A major gap in the literature is the use of the TOMM amongst culturally Deaf individuals who use American Sign Language (ASL) as their first and preferred language. The purpose of this study was to explore the use of the TOMM with this population to determine if there may be differences related to the use of semantic knowledge and recall using signs rather than spoken phonemes.

METHOD

This study recruited 30 culturally Deaf, community-dwelling adults, who self-reported that they were not involved in litigation ordisability claims. In addition to the TOMM, participants were screened for cognitive ability using non-verbal components of the Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II) and the Mini Mental State Examination: ASL Version (MMSE:ASL).

RESULTS

Nonverbal intelligence for this sample was within the average range of ability. No participants scored lower than the standard cut-off score for Trial 2 or the Retention Trial on the TOMM (≤44 raw score to indicate invalid responding). Trial 1 performances ranged from 44 to 50, Trial 2 performances ranged from 49 to 50, and Retention performances ranged from 49 to 50.

CONCLUSION

These results support the use of the same standard cut-off scores established for hearing individuals in culturally Deaf individuals who use ASL.

Cross-validation of the Invalid Forgetting Frequency Index (IFFI) from the Test of Memory Malingering

Objective

To increase sensitivity of the Test of Memory Malingering (TOMM), adjustments have been proposed, including adding consistency indices. The Invalid Forgetting Frequency Index (IFFI) is the most recently developed consistency index. While strong classification accuracy rates were originally reported, it currently lacks cross-validation.

Method

A sample of 184 outpatients was utilized. Valid performers passed all criterion performance validity tests (PVTs) and invalid performers failed two or more PVTs. Classification accuracy statistics were calculated.

Results

AUC for the IFFI was 0.80, demonstrating adequate discrimination between valid and invalid groups. A score of 3 or more inconsistent responses resulted in sensitivity and specificity rates of 63% and 92%, respectively.

Conclusions

This is the first article to cross-validate the IFFI. In both the original IFFI study and the current study, the same cut-off was found to maintain at least 90% specificity while producing higher sensitivity rates than those achieved by traditional TOMM indices.

Effects of Distraction on Performance Validity: A Pilot Study with Veterans

OBJECTIVE

The purpose of this experimental pilot study was to evaluate whether distraction can affect results of performance validity testing.

METHOD

Thirty-three veterans who have served in the US military since 09/11/2001 (Mage = 38.60, SD = 10.85 years) completed the Test of Memory Malingering (TOMM), Trail Making Test, and Medical Symptom Validity Test (MSVT). Subjects were randomly assigned to complete the MSVT in one of three experimental conditions: standard administration, while performing serial 2 s (Cognitive Distraction), and while submerging a hand in ice water (Physical Distraction).

RESULTS

All participants included in primary analyses passed the TOMM (n = 30). Physical distraction did not affect performance on the MSVT. Cognitive distraction negatively affected MSVT performance.

CONCLUSIONS

Cognitive distraction can substantially affect MSVT performance in a subgroup of individuals. Physical distraction did not significantly affect MSVT performance.

When Time is of the Essence: Preliminary Findings for a Quick Administration of the Dot Counting Test

Objective

Performance validity research has emphasized the need for briefer measures and, more recently, abbreviated versions of established free-standing tests to minimize neuropsychological evaluation costs/time burden. This study examined the accuracy of multiple abbreviated versions of the Dot Counting Test (“quick” DCT) for detecting invalid performance in isolation and in combination with the Test of Memory Malingering Trial 1 (TOMMT1).

Method

Data from a mixed clinical sample of 107 veterans (80 valid/27 invalid per independent validity measures and structured criteria) were included in this cross-sectional study; 47% of valid participants were cognitively impaired. Sensitivities/specificities of various 6- and 4-card DCT combinations were calculated and compared to the full, 12-card DCT. Combined models with the most accurate 6- and 4-card combinations and TOMMT1 were then examined.

Results

Receiver operator characteristic curve analyses were significant for all 6- and 4-card DCT combinations with areas under the curve of .868–.897. The best 6-card combination (cards, 1-3-5-8-11-12) had 56% sensitivity/90% specificity (E-score cut-off, ≥14.5), and the best 4-card combination (cards, 3-4-8-11) had 63% sensitivity/94% specificity (cut-off, ≥16.75). The full DCT had 70% sensitivity/90% specificity (cut-off, ≥16.00). Logistic regression revealed 95% classification accuracy when 6-card or 4-card “quick” combinations were combined with TOMMT1, with the DCT combinations and TOMMT1 both emerging as significant predictors.

Conclusions

Abbreviated DCT versions utilizing 6- and 4-card combinations yielded comparable sensitivity/specificity as the full DCT. When these “quick” DCT combinations were further combined with an abbreviated memory-based performance validity test (i.e., TOMMT1), overall classification accuracy for identifying invalid performance was 95%.

They're not just little adults: The utility of adult performance validity measures in a mixed clinical pediatric sample

Performance validity tests (PVTs) have become a standard part of adult neuropsychological practice; however, they are less widely used in pediatric testing. The current study aimed to obtain a better understanding of the application of PVTs within a mixed clinical pediatric sample with a wide range of diagnosis, IQ, and age. Cross-sectional data were analyzed from 130 consecutive pediatric patients evaluated as part of clinical care and diagnosed with a variety of medical/neurological, developmental, and psychiatric disorders. Patients were administered a battery of neuropsychological tests; results of intellectual functioning measures (i.e., Wechsler Intelligence Scale for Children-Fifth Edition [WISC-V] or Wechsler Adult Intelligence Scale-Fourth Edition [WAIS-IV]), and PVTs (i.e., Test of Memory Malingering [TOMM] and Digit Span [DS] subtests of the WISC-V/WAIS-IV) were analyzed to assess PVT performance across the sample as well as age- and Full-Scale IQ-related (FSIQ) effects on pass rate. Results suggested that the TOMM is an effective validity test for youth, as the TOMM adult cutoff score was also valid for children (88% pass rate on TOMM trial 1 cut-score ≥41, 71% pass rate on TOMM trial 1 cut-score ≥45). In contrast, Reliable Digit Span (RDS) was less accurate (34% failed RDS [cut-score ≤6], 54% failed RDS-r [cut-score ≤10], and 25% failed DS ACSS [cut-score ≤5]) using standard adult cutoffs. Notably, although TOMM scores were not strongly influenced by IQ, DS scores increased as IQ increased. Overall, further analysis of PVTs can champion new standards of practice through additional research establishing PVT accuracy within pediatric populations.

Clinical utility of WAIS-IV 'excessive decline from premorbid functioning' scores to detect invalid test performance following traumatic brain injury

Objective: Excessive Decline from Premorbid Functioning (EDPF), an atypical discrepancy between demographically predicted and obtained Wechsler Adult Intelligence Scale-4th Edition (WAIS-IV) scores, has been recently proposed as a potential embedded performance validity test (PVT). This study examined the clinical utility of EDPF scores to detect invalid test performance following traumatic brain injury (TBI).Methods: Participants were 194 U.S. military service members who completed neuropsychological testing on average 2.4 years (SD = 4.0) following uncomplicated mild, complicated mild, moderate, severe, or penetrating TBI (Age: M = 34.0, SD = 9.9). Using TBI severity and PVT performance (i.e., PVT Pass/Fail), participants were classified into three groups: Uncomplicated Mild TBI-PVT Fail (MTBI-Fail; n = 21), Uncomplicated Mild TBI-PVT Pass (MTBI-Pass; n = 94), and Complicated Mild to Severe/Penetrating TBI-PVT Pass (CM/STBI-Pass; n = 79). Seven EDPF measures were calculated by subtracting WAIS-IV obtained index scores from the demographically predicted scores from the Test of Premorbid Functioning (TOPF). Cutoff scores to detect invalid test performance were examined for each EDPF measure separately.Results: The MTBI-Fail group had higher scores than the MTBI-Pass and CM/STBI-Pass groups on five of the seven EDPF measures (p<.05). Overall, the EDPF measure using the Processing Speed Index (EDPF-PSI) was the most useful score to detect invalid test performance. However, sensitivity was only low to moderate depending on the cutoff score used.Conclusions: These findings provide support for the use of EDPF as an embedded PVT to be considered along with other performance validity data when administering the WAIS-IV.

The effect of literacy and culture on cognitive effort test performance: An examination of the Test of Memory Malingering in Colombia

Introduction: Cognitive efforts tests, such as the Test of Memory Malingering (TOMM), are widely used internationally, yet emerging research suggests that performance on the TOMM can be affected by culture and education. This study examined the specificity of the TOMM and performance differences among Colombian adults, contrasting those with varying levels of literacy in order to evaluate the impact of these variables on error rates. It was hypothesized that literacy would be positively correlated with TOMM scores. Method: The sample consisted of 256 participants: the Absolute Illiterate participants had no formal education and no ability to read or write (n = 58), Functional Illiterate participants had no formal education and only basic reading and writing skills (n = 66), Literate participants had up to 12-years of education (n = 66), and Highly Literate participants had some post-secondary education (n = 66). Group differences for Trial 1 (T1) and Trial 2 (T2) were analyzed using ANOVAs and chi-square tests, along with post-hoc comparisons. Results: Mean T2 scores for the four groups were all above the suggested cutoff score of 45: the Highly Literate group had the highest mean score (49.3, range 41 to 50), and the Absolute Illiterate group had the lowest mean score (45.5, range 30 to 50). The Absolute and Functional Illiterate groups performed significantly worse on the TOMM trials than the literate participants. Cognitive performance as measured by indicators of verbal fluency and executive control significantly correlated with TOMM performance. However, when evaluated together in hierarchical logistic regressions, only age and literacy significantly predicted TOMM scores. Conclusions: Although the performance of Colombian adults suggests that the TOMM can be used cross-culturally with literate individuals, Colombian adults with poorer literacy skills performed significantly worse, raising concerns regarding the use of this measure with educationally-diverse samples. Research and clinical implications are discussed.

Impact of criterion measures on the classification accuracy of TOMM-1

This study was designed to examine the effect of various criterion measures on the classification accuracy of Trial 1 of the Test of Memory Malingering (TOMM-1), a free-standing performance validity test (PVT). Archival data were collected from a case sequence of 91 (M _Age = 42.2 years; M _Education = 12.7) patients clinically referred for neuropsychological assessment. Trials 2 and Retention of the TOMM, the Word Choice Test, and three validity composites were used as criterion PVTs. Classification accuracy varied systematically as a function of criterion PVT. TOMM-1 ≤ 43 emerged as the optimal cutoff, resulting in a wide range of sensitivity (.47-1.00), with perfect overall specificity. Failing the TOMM-1 was unrelated to age, education or gender, but was associated with elevated self-reported depression. Results support the utility of TOMM-1 as an independent, free-standing, single-trial PVT. Consistent with previous reports, the choice of criterion measure influences parameter estimates of the PVT being calibrated. The methodological implications of modality specificity to PVT research and clinical/forensic practice should be considered when evaluating cutoffs or interpreting scores in the failing range.

Performance Validity, Neurocognitive Disorder, and Post-concussion Symptom Reporting in Service Members with a History of Mild Traumatic Brain Injury

Objective

To examine the influence of different performance validity test (PVT) cutoffs on neuropsychological performance, post-concussion symptoms, and rates of neurocognitive disorder and postconcussional syndrome following mild traumatic brain injury (MTBI) in active duty service members.

Method

Participants were 164 service members (Age: M = 28.1 years [SD = 7.3]) evaluated on average 4.1 months (SD = 5.0) following injury. Participants were divided into three mutually exclusive groups using original and alternative cutoff scores on the Test of Memory Malingering (TOMM) and the Effort Index (EI) from the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS): (a) PVT-Pass, n = 85; (b) Alternative PVT-Fail, n = 53; and (c) Original PVT-Fail, n = 26. Participants also completed the Neurobehavioral Symptom Inventory.

Results

The PVT-Pass group performed better on cognitive testing and reported fewer symptoms than the two PVT-Fail groups. The Original PVT-Fail group performed more poorly on cognitive testing and reported more symptoms than the Alternative PVT-Fail group. Both PVT-Fail groups were more likely to meet DSM-5 Category A criteria for mild and major neurocognitive disorder and symptom reporting criteria for postconcussional syndrome than the PVT-Pass group. When alternative PVT cutoffs were used instead of original PVT cutoffs, the number of participants with valid data meeting cognitive testing criteria for neurocognitive disorder or postconcussional syndrome decreased dramatically.

Conclusion

PVT performance is significantly and meaningfully related to overall neuropsychological outcome. By using only original cutoffs, clinicians and researchers may miss people with invalid performances.

Cross-validation of three Advanced Clinical Solutions performance validity tests: Examining combinations of measures to maximize classification of invalid performance

Use of multiple performance validity tests (PVTs) may best identify invalid performance, though few studies have examined the utility and accuracy of combining PVTs. This study examined the following PVTs in the Advanced Clinical Solutions (ACS) package to determine their utility alone and in concert: Word Choice Test (WCT), Reliable Digit Span (RDS), and Logical Memory Recognition (LMR). Ninety-three veterans participated in clinical neuropsychological evaluations to determine presence of cognitive impairment; 25% of the performances were deemed invalid via criterion PVTs. Classification accuracy of the ACS measures was assessed via receiver operating characteristic curves, while logistic regressions determined utility of combining these PVTs. The WCT demonstrated superior classification accuracy compared to the two embedded measures of the ACS, even in veterans with cognitive impairment. The two embedded measures (even when used in concert) exhibited inadequate classification accuracy. A combined model with all three ACS PVTs similarly demonstrated little benefit of the embedded indicators over the WCT alone. Results suggest the ACS WCT has utility for detecting invalid performance in a clinical sample with likely cognitive impairment, though the embedded ACS measures (RDS and LMR) may have limited incremental utility, particularly in individuals with cognitive impairment.

Plasma Tau and Amyloid Are Not Reliably Related to Injury Characteristics, Neuropsychological Performance, or White Matter Integrity in Service Members with a History of Traumatic Brain Injury

The aim of this study was to examine the relationship between plasma tau and amyloid beta-42 (Aβ42), neuropsychological functioning, and white matter integrity in U.S. military service members with (n = 155) and without (n = 42) a history of uncomplicated mild (n = 83), complicated mild (n = 26), or moderate, severe, or penetrating (n = 46) traumatic brain injury (TBI). We hypothesized that higher levels of tau and Aβ42 would be related to reduced neurocognitive performance and white matter integrity. Participants were enrolled prospectively from Walter Reed National Military Medical Center. Participants completed a blood draw, neuropsychological assessment, and diffusion tensor imaging (General Electric 3T) of the whole brain. From 20 neuropsychological test scores, five cognitive domain scores were computed. Measures of fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were generated for 18 regions of interest (ROIs). There was no relationship found between the plasma biomarkers and neurocognitive performance in any of the three TBI groups (all ps >0.05; all R² changes <0.146). Although not reaching statistical significance after correction for multiple comparisons, higher tau and Aβ42 tended to be related to higher FA and lower MD, RD, and AD in patients with a history of moderate, severe, or penetrating TBI. There was no consistent relationship between either of the biomarkers and white matter integrity in the complicated and uncomplicated mild TBI groups. In addition, there was no significant relationship between the biomarkers and age, education, sex, race, bodily injury severity, time since injury, TBI severity, or number of TBIs (all ps >0.15). Future investigation in larger samples of moderate, severe, and penetrating TBI are needed. Other plasma biomarkers, including phosphorylated tau, exosomal tau, and interleukin-10, may be more promising measures to use in the diagnosis, management, and treatment of TBI.

When 10 is enough: Errors on the first 10 items of the Test of Memory Malingering (TOMMe10) and administration time predict freestanding performance validity tests (PVTs) and underperformance on memory measures

It is critical that we develop more efficient performance validity tests (PVTs). A shorter version of the Test of Memory Malingering (TOMM) that utilizes errors on the first 10 items (TOMMe10) has shown promise as a freestanding PVT. Retrospective review included 397 consecutive veterans administered TOMM trial 1 (TOMM1), the Medical Symptom Validity Test (MSVT), and the Brief Visuospatial Memory Test-Revised (BVMT-R). TOMMe10 accuracy and administration time were used to predict performance on freestanding PVTs (TOMM1, MSVT). The impact of failing TOMMe10 (2 or more errors) on independent memory measures was also explored. TOMMe10 was a robust predictor of TOMM1 (area under the curve [AUC] = 0.97) and MSVT (AUC = 0.88) with sensitivities = 0.76 to 0.89 and specificities = 0.89 to 0.96. Administration time predicted PVT performance but did not improve accuracy compared to TOMMe10 alone. Failing TOMMe10 was associated with clinically and statistically significant declines on the BVMT-R and MSVT Paired Associates and Free Recall memory tests (d = -0.32 to -1.31). Consistent with prior research, TOMMe10 at 2 or more errors was highly accurate in predicting performance on other well-validated freestanding PVTs. Failing just 1 freestanding PVT (TOMMe10) significantly impacted memory measures and likely reflects invalid test performance.

Associations between neuropsychiatric and health status outcomes in individuals with probable mTBI

Mild traumatic brain injury (mTBI) is a common occurrence, and may impact distal outcomes in a subgroup of individuals. Improved characterization of health outcomes and identification of factors associated with poor outcomes is needed to better understand the impact of mTBI, particularly in those with co-occurring posttraumatic stress disorder (PTSD). Participants in a data repository of the Injury and Traumatic Stress (INTRuST) Clinical Consortium (n = 625) completed functional disability [FD] and health-related quality of life [HRQOL] questionnaires, and a subset completed a neuropsychological assessment. FD and HRQOL were compared among participants with probable mTBI (mTBI), probable mTBI with PTSD (mTBI/PTSD), and health comparison participants (HC). Associations between symptoms, neuropsychological performance, and health outcomes were examined in those with probable mTBI with and without PTSD (n = 316). Individuals in the mTBI/PTSD group endorsed poorer health outcomes than those in the mTBI group, who endorsed poorer outcomes than those in the HC group. Individuals in either mTBI group performed worse than those in the HC on verbal learning and memory and psychomotor speed. Health outcomes were correlated with mental health and postconcussive symptoms, as well as neuropsychological variables. mTBI may adversely impact self-reported health, with the greatest effect observed in individuals with co-occurring mTBI/PTSD.

Five-factor structure of the RBANS is supported in an Alzheimer's disease sample: Implications for validation of neuropsychological assessment instruments

Development of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was theoretically driven, with the goal of providing an assessment of abilities across five cognitive domains. Since its development, numerous factor analytic studies have failed to provide empirical support for the proposed five-factor structure and, furthermore, have lacked consensus on the internal structure of this instrument. A key limitation of these prior studies is the use of normal or mixed clinical samples, a practice that can obscure distinctions that may be evident in specific homogeneous clinical samples. The current study examined the factor structure of the RBANS in a sample of 107 male Veterans diagnosed with probable Alzheimer's disease (AD). Confirmatory factor analysis of a model reflecting the five Index Scores (Immediate Memory, Visuospatial/Constructional, Language, Attention, and Delayed Memory) found that the proposed five-factor structure fit the data well. These findings suggest that the RBANS does measure five distinct constructs and use of Index Scores is appropriate. Furthermore, the current findings highlight the importance of testing construct validity of neuropsychological assessment instruments in specific homogeneous samples.