Differences in performance on the test of variables of attention between credible vs. noncredible individuals being screened for attention deficit hyperactivity disorder

The experience of effort in ADHD: a scoping review

Background

Mental effort plays a critical role in regulating cognition. However, the experience of mental effort may differ for individuals with Attention-Deficit/Hyperactivity Disorder (ADHD), a disorder for which sustained mental effort 'avoidance' or 'dislike' is a criterion in the DSM. We conducted a scoping review to characterize the literature on the experiences of effort in ADHD.

Methods

This systematic scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews and Joanna Briggs Methodology. PsycINFO (OVID), PsycINFO (ProQuest) and PubMed were searched for studies published in English before February 14, 2023. Studies must have included an ADHD population or a measure of ADHD symptomatology, in addition to a self-report measure of the experience of effort or the use of an effort preference paradigm. Two researchers reviewed all abstracts, and one researcher reviewed full-text articles.

Results

Only 12 studies met the inclusion criteria. Several gaps and inconsistencies in the research were identified in terms of method, definitions of effort, measurements of ADHD, and sample characteristics. Moreover, the pattern of results on the experience of effort was mixed.

Conclusion

Despite its diagnostic and conceptual significance, the experience of mental effort in ADHD is not well studied. Critical gaps were identified in the existing literature. A three-facet conceptualization of effort is proposed-specifically, task-elicited effort, volitionally exerted effort, and the affect associated with engaging in effort - to guide future explorations of the experience of effort in ADHD.

Performance Validity Test Failure in the Clinical Population: A Systematic Review and Meta-Analysis of Prevalence Rates

Performance validity tests (PVTs) are used to measure the validity of the obtained neuropsychological test data. However, when an individual fails a PVT, the likelihood that failure truly reflects invalid performance (i.e., the positive predictive value) depends on the base rate in the context in which the assessment takes place. Therefore, accurate base rate information is needed to guide interpretation of PVT performance. This systematic review and meta-analysis examined the base rate of PVT failure in the clinical population (PROSPERO number: CRD42020164128). PubMed/MEDLINE, Web of Science, and PsychINFO were searched to identify articles published up to November 5, 2021. Main eligibility criteria were a clinical evaluation context and utilization of stand-alone and well-validated PVTs. Of the 457 articles scrutinized for eligibility, 47 were selected for systematic review and meta-analyses. Pooled base rate of PVT failure for all included studies was 16%, 95% CI [14, 19]. High heterogeneity existed among these studies (Cochran's Q = 697.97, p < .001; I2 = 91%; τ2 = 0.08). Subgroup analysis indicated that pooled PVT failure rates varied across clinical context, presence of external incentives, clinical diagnosis, and utilized PVT. Our findings can be used for calculating clinically applied statistics (i.e., positive and negative predictive values, and likelihood ratios) to increase the diagnostic accuracy of performance validity determination in clinical evaluation. Future research is necessary with more detailed recruitment procedures and sample descriptions to further improve the accuracy of the base rate of PVT failure in clinical practice.

Cognitive Underperformance in a Mixed Neuropsychiatric Sample at Diagnostic Evaluation of Adult ADHD

(1) Background: The clinical assessment of attention-deficit/hyperactivity disorder (ADHD) in adulthood is known to show non-trivial base rates of noncredible performance and requires thorough validity assessment. (2) Objectives: The present study estimated base rates of noncredible performance in clinical evaluations of adult ADHD on one or more of 17 embedded validity indicators (EVIs). This study further examines the effect of the order of test administration on EVI failure rates, the association between cognitive underperformance and symptom overreporting, and the prediction of cognitive underperformance by clinical information. (3) Methods: A mixed neuropsychiatric sample (N = 464, ADHD = 227) completed a comprehensive neuropsychological assessment battery on the Vienna Test System (VTS; CFADHD). Test performance allows the computation of 17 embedded performance validity indicators (PVTs) derived from eight different neuropsychological tests. Further, all participants completed several self- and other-report symptom rating scales assessing depressive symptoms and cognitive functioning. The Conners' Adult ADHD Rating Scale and the Beck Depression Inventory-II were administered to derive embedded symptom validity measures (SVTs). (4) Results and conclusion: Noncredible performance occurs in a sizeable proportion of about 10% up to 30% of individuals throughout the entire battery. Tests for attention and concentration appear to be the most adequate and sensitive for detecting underperformance. Cognitive underperformance represents a coherent construct and seems dissociable from symptom overreporting. These results emphasize the importance of performing multiple PVTs, at different time points, and promote more accurate calculation of the positive and negative predictive values of a given validity measure for noncredible performance during clinical assessments. Future studies should further examine whether and how the present results stand in other clinical populations, by implementing rigorous reference standards of noncredible performance, characterizing those failing PVT assessments, and differentiating between underlying motivations.

Base rates of non-credible performance in a post-secondary student sample seeking accessibility accommodations

Objective: Performance Validity Tests (PVTs) have been used to identify non-credible performance in clinical, medicolegal, forensic, and, more recently, academic settings. The inclusion of PVTs when administering psychoeducational assessments is essential given that specific accommodation such as flexible deadlines and increased writing time can provide an external incentive for students without disabilities to feign symptoms. Method: The present study used archival data to establish base rates of non-credible performance in a sample of post-secondary students (n = 1045) who underwent a comprehensive psychoeducational evaluation for the purposes of obtaining academic accommodations. In accordance with current guidelines, non-credible performance was determined by failure on two or more freestanding or embedded PVTs. Results: 9.4% of participants failed at least two of the PVTs they were administered, of which 8.5% failed two PVTs, and approximately 1% failed three PVTs. Base rates of failure for specific PVTs ranged from 25% (b Test) to 11.2% (TOVA). Conclusions: The present study found a lower base rate of non-credible performance than previously observed in comparable populations. This likely reflects the utilization of conservative criteria in detecting non-credible performance to avoid false positives. By contrast, inconsistent base rates previously found in the literature may reflect inconsistent methodologies. These results further emphasize the importance of administering multiple PVTs during psychoeducational assessments. The implications of these findings can further inform clinicians administering assessments in academic settings and aid in the appropriate utilization of PVTs in psychoeducational evaluation to determine accessibility accommodations.

Feigning Adult ADHD on a Comprehensive Neuropsychological Test Battery: An Analogue Study

The evaluation of performance validity is an essential part of any neuropsychological evaluation. Validity indicators embedded in routine neuropsychological tests offer a time-efficient option for sampling performance validity throughout the assessment while reducing vulnerability to coaching. By administering a comprehensive neuropsychological test battery to 57 adults with ADHD, 60 neurotypical controls, and 151 instructed simulators, we examined each test's utility in detecting noncredible performance. Cut-off scores were derived for all available outcome variables. Although all ensured at least 90% specificity in the ADHD Group, sensitivity differed significantly between tests, ranging from 0% to 64.9%. Tests of selective attention, vigilance, and inhibition were most useful in detecting the instructed simulation of adult ADHD, whereas figural fluency and task switching lacked sensitivity. Five or more test variables demonstrating results in the second to fourth percentile were rare among cases of genuine adult ADHD but identified approximately 58% of instructed simulators.

Attention Performance as an Embedded Validity Indicator in the Cognitive Assessment of Early Retirement Claimants

The assessment of performance validity is essential in any neuropsychological evaluation. However, relatively few measures exist that are based on attention performance embedded within routine cognitive tasks. The present study explores the potential value of a computerized attention test, the Cognitrone, as an embedded validity indicator in the neuropsychological assessment of early retirement claimants. Two hundred and sixty-five early retirement claimants were assessed with the Word Memory Test (WMT) and the Cognitrone. WMT scores were used as the independent criterion to determine performance validity. Speed and accuracy measures of the Cognitrone were analyzed in receiver operating characteristics (ROC) to classify group membership. The Cognitrone was sensitive in revealing attention deficits in early retirement claimants. Further, 54% (n = 143) of the individuals showed noncredible cognitive performance, whereas 46% (n = 122) showed credible cognitive performance. Individuals failing the performance validity assessment showed slower (AUC = 79.1%) and more inaccurate (AUC = 79.5%) attention performance than those passing the performance validity assessment. A compound score integrating speed and accuracy revealed incremental value as indicated by AUC = 87.9%. Various cut scores are suggested, resulting in equal rates of 80% sensitivity and specificity (cut score = 1.297) or 69% sensitivity with 90% specificity (cut score = 0.734). The present study supports the sensitivity of the Cognitrone for the assessment of attention deficits in early retirement claimants and its potential value as an embedded validity indicator. Further research on different samples and with multidimensional criteria for determining invalid performance are required before clinical application can be suggested.

Symptom and performance validity in samples of adults at clinical evaluation of ADHD: a replication study using machine learning algorithms

INTRODUCTION

Research has shown non-trivial base rates of noncredible symptom report and performance in the clinical evaluation of attention-deficit/hyperactivity disorder (ADHD) in adulthood. The goal of this study is to estimate and replicate base rates of symptom and performance validity test failure in the clinical evaluation of adult ADHD and derive prediction models based on routine clinical measures.

METHODS

This study reuses data of a previous publication of 196 adults seeking ADHD assessment and replicates the findings on an independent sample of 700 adults recruited in the same referral context. Measures of symptom and performance validity (one SVT, two PVTs) were applied to estimate base rates. Prediction models were developed using machine learning.

RESULTS

Both samples showed substantial rates of noncredible symptom report (one SVT failure: 35.7% - 36.6%), noncredible test performance (one PVT failure: 32.1% - 49.3%; two PVT failures: 18.9% - 27.3%), or both (each one SVT and PVT failure: 13.3% - 22.4%; one SVT and two PVT failures: 9.7% - 13.7%). Machine learning algorithms resulted in generally moderate to weak prediction models, with advantages of the reused sample compared to the independent replication sample. Associations between measures of symptom and performance validity were negligible to small.

CONCLUSIONS

This study highlights the necessity to include measures of symptom and performance validity in the clinical evaluation of adult ADHD. Further, this study demonstrates the difficulty to characterize the group failing symptom or performance validity assessment.

Motor Reaction Times as an Embedded Measure of Performance Validity: a Study with a Sample of Austrian Early Retirement Claimants

Among embedded measures of performance validity, reaction time parameters appear to be less common. However, their potential may be underestimated. In the German-speaking countries, reaction time is often examined using the Alertness subtest of the Test of Attention Performance (TAP). Several previous studies have examined its suitability for validity assessment. The current study was conceived to examine a variety of reaction time parameters of the TAP Alertness subtest with a sample of 266 Austrian civil forensic patients. Classification results from the Word Memory Test (WMT) were used as an external indicator to distinguish between valid and invalid symptom presentations. Results demonstrated that the WMT fail group performed worse in reaction time as well as its intraindividual variation across trials when compared to the WMT pass group. Receiver operating characteristic analyses revealed areas under the curve of .775–.804. Logistic regression models indicated the parameter intraindividual variation of motor reaction time with warning sound as being the best predictor for invalid test performance. Suggested cut scores yielded a sensitivity of .62 and a specificity of .90, or .45 and .95, respectively, when the accepted false-positive rate was set lower. The results encourage the use of the Alertness subtest as an embedded measure of performance validity.

What can we learn about performance validity from TOVA response profiles?

Given the functional impairments associated with Attention Deficit/Hyperactivity Disorder (AD/HD), a valid diagnosis is important. However, particularly when carried out in adulthood, the diagnostic process can be challenging and is complicated by conclusive evidence that a proportion of individuals referred for evaluation of AD/HD exaggerate or feign their symptoms. Relatively few methods, however, exist to identify such feigning. While continuous performance tests (CPTs) may provide useful information regarding performance validity, the question remains as to whether there are consistent patterns of exaggeration demonstrated by those feigning AD/HD. Thus, this study used cluster analysis to determine whether valid and reliable performance clusters would emerge based on CPT performance. Using archival data from a university-based AD/HD screening clinic, we investigated the performance of 305 adults on the Test of Variables of Attention (TOVA). Three profiles emerged, including one cluster who demonstrated exceptionally low performance on the TOVA, exceptionally high reports of AD/HD symptomology, and higher rates of failure on symptom and performance validity tests. The implication from our analysis is that this group most likely represents individuals who were exaggerating or magnifying their difficulties. The results reaffirm previous research showing that performance profiles on a continuous performance test can be used as an indicator of credible performance.

Sluggish Cognitive Tempo Factors in Emerging Adults:Symptomatic and Neuropsychological Correlates

We examined whether there are factors of SCT in nonclinical young adults and whether SCT factors show differential relationships with depression, anxiety, ADHD, and executive functioning as assessed by self-report (EF-SR) or neuropsychological performance (EF-NP). Factor analysis revealed Daydreaming/Bored (D/B), Lethargy (L), and Cognitive Complaints (CC) factors. CC was associated with anxiety and D/B with depression. CC and D/B were associated with inattentive ADHD, while D/B was associated with hyperactive/impulsive ADHD. While all factors were associated with EF-SR, there were few relationships with EF-NP. Higher CC was associated with lower intellect, and higher D/B was related to better working memory.

Feigning ADHD and stimulant misuse among Dutch university students

The increasing number of university students seeking diagnosis of attention-deficit/hyperactivity disorder (ADHD), and findings of an increased stimulant misuse among university students, has raised concerns regarding the credibility of the symptoms of those students. However, most of our current knowledge refers to university students in North America and less is known about this issue on European campuses. The present survey aimed to collect opinions on feigning ADHD and to estimate the prevalence of stimulant misuse among 1071 university students in the Netherlands. The majority of students expressed liberal attitudes towards feigning ADHD. Also, a substantial number of respondents considered feigning ADHD themselves or know someone who feigns ADHD. Furthermore, 68% of students assumed benefits of taking stimulants without prescription and 16% have indeed already taken stimulants without prescription. Feigning ADHD and misuse of prescription medication are prevalent issues among Dutch students. The results underline the need for a careful diagnostic evaluation of individuals for ADHD. Furthermore, efforts are required in order to prevent stimulant drug trafficking and misuse among university students.