A Dissertation. Submitted to the Faculty. Xavier University. in Partial Fulfillment of the. Requirements for the Degree of. Doctor of Psychology

Transcription

1 A Dissertation Submitted to the Faculty of Xavier University in Partial Fulfillment of the Requirements for the Degree of Doctor of Psychology by Julianne Gast, M.A. January, 2009 Approved: Christine M. Dacey, Ph.D., ABPP Chair, Department o f Psychology Kajhleen, J. Hart, P h ^, ABPP Dissertation Chair

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3 The Performance of Juvenile Delinquents on the Test o f Memory Malingering (TOMM)

4 UMl Number: DP20275 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. UMI Ois»«ft*tion Publishing UMI DP20275 Published by ProQuest LLC (2013). Copyright in the Dissertation held by the Author. Microform Edition ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code uesf ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml

5 Dissertation Committee Chair Member Member Kathleen J. Hart, Ph.D., ABPP Professor of Psychology Susan Kenford, Ph.D. Associate Professor o f Psychology Myron Fridman, Ph.D. Psychologist

6 Acknowledgements This dissertation would not have been possible without the help and support of many wonderful people. First, I wish to extend my appreciation to my advisor. Dr. Kathleen Hart, for her knowledge, patience and guidance in assisting me with this project. Thank you for challenging me and always providing me with the motivation and tools to move forward. I also wish to thank my committee members. Dr. Susan Kenford and Dr. Myron Fridman, for their insights and expertise, and for giving their valuable time and constructive feedback. I am deeply indebted to Dr. Carla Dreyer who provided me with invaluable assistance during my data collection for this project. She truly went above and beyond to help me, and I don't think I would have ever finished this project if it weren t for her generous giving of her input, time and energy. I would also like to thank all my friends, particularly, Meghan, Amber, Julia, Matt and Jaime, for providing me with instrumental and emotional support throughout all the stages o f my research. I always knew I could count on you to help me relax, kick my feet up and take some time to have fun Finally, I want to express deep gratitude to my family for always providing me with all kinds of support and encouragement throughout the last six years. Especially, to my parents, who have shown me the importance of hard work and dedication which has helped me to reach my goals. To Matthew, my husband, whose love, understanding and constant patience have taught me so much about compromise, discipline and sacrifice.

7 Table of Contents Page Acknowledgements... i Table o f Contents...n List of Tables... iii List of Appendices... iv Chapter I. Revi ew of Literature... 1 II. III. IV. Rationale and Hypothesis...28 M ethod...30 Proposed Analyses...36 References Appendices...50 V. Dissertation...56 References Tables...83 Appendices...92 II

8 List of Tables Table Proposal Page 1. Rogers (1997) Proposed Response Styles...3 Chapter V 1. Demographic characteristics o f whole sample and IQ groups Primary Axis I diagnoses, Axis I rule out diagnoses, and Axis II diagnoses Summary o f immediate adjudications Mean TOMM scores of entire sample Mean TOMM scores by IQ group Means and standard deviations o f normative groups used for comparison,., One sample t-test results for whole sample and IQ groups comparing to normative groups Correlations between TOMM performance and demographic data Means, standard deviations and percentages of effort ratings

9 List o f Appendices Proposal Page A. Research Studies using the Test of Memory Malingering Chapter V A. Letter from Superintendant of Hillcrest Training School B. Approval Letter from Xavier University IRB IV

10 Juvenile TOMM 1 Chapter I Review of the Literature Over the course of the last 20 years, psychologists and neuropsychologists have paid increasing attention to the role effort, response style and malingering play in evaluee s test performance, especially when the clinical encounter is for legal or forensic reasons. There are various ways this has been studied. Early studies focused primarily on detecting malingering (Pankratz, 1988), whereas more recent studies have broadened to examine the roles that effort and response styles play in evaluees test performance (Rogers, 1997; Tombaugh, 1997). Malingering Malingering is defined as the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty or work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs (American Psychiatric Association, 2000). The DSM-JV-TR (2000) describes four features that suggest one may be malingering. The first criterion is a medicolegal context of presentation. For example, the person has been referred to the clinician by an attorney for an examination or is involved in (or considering) a lawsuit. Next, there is a marked discrepancy between the person s claimed stress or disability and the objective findings of the medical or psychological tests. Third, a person may be malingering if there is a lack of cooperation during the diagnostic evaluation and/or in complying with the prescribed treatment regimen. Lastly, the presence of antisocial personality disorder raises concerns about malingering. A combination of these four criteria suggests one may be malingering. Response Styles

11 Juvenile TOMM 2 Several experts (Frederick, 1997; Rogers, 1997) have suggested that malingering is too narrow a concept to capture what is of interest to clinicians performing psychological evaluations, especially in a psycholegal context. Over the course o f the last decade researchers and clinicians have moved away from the dichotomous view (i.e., malingering vs. not malingering) and suggested that evaluators consider the response style that an evaluee is using. Rogers has described a number o f response styles individuals might use when being evaluated. These are summarized in Table 1. Response styles may range from honest and consistent responding to defensive responding to malingering. The opposite of malingering is the defensive response style, in which a patient minimizes his or her symptoms in order to achieve an external goal. Honest responding is what most clinicians expect from their patients, although past research suggests that honest responding may be not be as common as once believed (Faust & Guilmette, 1990). Random responding is seen mostly on measures with a forced choice format, such as the Minnesota Multiphasic Personality Inventory (MMPI-2), and the intention o f this response style is unclear (Rogers, 1997). Dissimulation is also sometimes used to describe distortions in responding that are difficult to classify by the previous response styles. According to Rogers (1997), dissimulation is used to describe an individual who is deliberately fabricating or misrepresenting psychological symptoms. Rogers clarifies the meaning o f other terms that are related to response style. For example, deception is an all encompassing term to describe any and all attempts by an individual to distort his or her self reporting, which includes both dissimulation and all other forms of dishonesty. Unreliability is a nonspecific term used to describe an individual whose response style is not honest and self disclosing, but without respect to his or her intention.

12 Juvenile TOMM Table 1 Rogers (1997) Proposed Response Styles Response Style Definition Malingering The conscious fabrication or gross exaggeration of physical or psychological symptoms in order to achieve an external goal. Defensiveness The conscious denial or gross minimization of physical and/or psychological symptoms in order to achieve an external goal. Honest responding A person s sincere attempt to be accurate in his or her s responses. Irrelevant responding When a person does not become psychologically engaged in the assessment process and makes no effort to respond in an appropriate way. Random Responding Occurs most often on forced choice or multiple choice tests, when the person shows a chance performance pattern. Hybrid Responding When a mixture of two or more of the above patterns is observed. Note. Adapted from Rogers, R. (1997). Clinical Assessment o f Malingering and Deception (2" ed.). New York: The Guilford Press.

13 Juvenile TOMM 4 Rogers (1997) has argued that response styles fall on a gradient, rather than into dichotomous, mutually inclusive categories. He further separates malingering into gradations of mild, moderate and severe. Mild malingering occurs when there is unequivocal evidence that the person is attempting to malinger, primarily through exaggeration. Moderate malingering is when the person, either through exaggeration or fabrication, attempts to present him or herself as considerably more disturbed than is the case. Severe malingering is when the person is extreme in his or her fabrication of symptoms to the point that the presentation is preposterous. These response styles are not mutually exclusive, and a client could demonstrate some combination of response styles; Rogers refers to this as hybrid or irrelevant responding. Other psychologists have suggested using the term effort to describe an examinee s approach to evaluation. Frederick (1997) asserts that the potential validity of performance on cognitive testing is a function of motivation and effort. Motivation refers to the intention of the test taker to perform well or poorly. Effort is the intensity of application of true ability to perform well or poorly. Motivation and effort exert separate effects on test performance. For example, inaccurate test scores can result from poor effort, even when the examinee is motivated to perform well (Frederick, 2002). Frederick (2002) cross classified motivation and effort to produce four response styles: compliant, careless, malingered and irrelevant. Compliant responding is characterized by high effort and motivation to perform well. Test takers who are compliant are cooperative with the testing procedures and their performance accurately represents their ability. Careless test taking is also characterized by the motivation to do well, but these evaluees give incomplete effort to respond correctly. Careless test taking may result

14 Juvenile TOMM 5 from inattention, distraction or fatigue. Malingering is characterized by high effort, but with motivation to perform poorly. The test taker tries to feign cognitive deficits in a convincing manner. Finally, irrelevant responding is characterized by low effort and motivation to perform poorly. Irrelevant test takers may be disengaged from the task of responding correctly and may not care about the outcome o f the assessment (Frederick). Careless, irrelevant or malingering performances are considered to represent invalid performances, yielding test results that are of little assistance in understanding the examinee s abilities. Research methods Prior to the late 1980 s, there was little empirical study of malingering. Beginning at that time, however, psychologists began to understand that it was critical to consider the possibility of malingering in evaluations, particularly those conducted in a legal context. A response to this recognition was the study of measures already available to detect malingering (Bernard & Fowler, 1990; Frederick, 2002; Lee, Loiing & Martin, 1992) and the development o f new measures to assess for malingering (Binder, 1993a; Frederick, 1997; Hiscock & Hiscock, 1989; Slick, Hopp, Strauss & Thompson, 1997, Tombaugh, 1996). Many different research methods have been used to study measures to detect malingering. These include simulation design, known groups comparisons, and differential prevalence design. When a simulation design is used, participants without cognitive impairment are asked to adopt a particular response style (Rogers, 1997). Sometimes, simulators are asked to fabricate answers, and other times they may be asked to act as if they experience a particular impairment (e.g., brain damage). When the participants are asked to fabricate answers, they are not given strategies or direction about

15 Juvenile TOMM 6 how to engage with the test dishonestly. In contrast, participants who are asked to act impaired are asked to answer like a person with a specific impairment, and often are given information to assist them in faking a particular disorder or impairment. The simulators are usually compared to two other groups: a control group recruited from the same population as the simulators and a clinical group with disorders that are likely to be malingered or exaggerated. Pankratz (1988) has criticized research with simulators as problematic, because it is based on the incorrect assumptions that malingerers are normal people who deceive and that more intelligent persons are better deceivers. Studies have also shown that percent of research participants are unwilling to simulate, even when given incentives (Heaton, Smith, Lehman & Vogt, 1978; Rogers). In some studies, noncompliant simulators have reported that they are too honest to fake or too motivated to do less than their best (e.g., Guilmette, Hart & Guiliano, 1993). Some participants also see through the measure and perform well because they think even impaired people would. A known groups comparison research method examines people in clinical settings who have already been identified as having malingered (Rogers, 1997). This group is then compared to another group of people who are known or assumed to be honest responders. The challenge of this design is the accurate classification of malingering and honest responders. Because there is no definitive means of classifying responders, each o f these groups could include misclassified individuals. There is also the risk that that the groups may not be representative of all malingerers or honest responders. A strength of known groups comparison is its generalizability to different settings. By studying actual malingerers, the resulting data are directly applicable to similar persons in other settings. Differential prevalence design is similar to known groups comparison in that people with different disorders or from different settings are postulated to have different rates o f

16 Juvenile TOMM 7 malingering (Rogers, 1997). Participants are not classified as malingering or honest responders. Since participants are not classified as malingering or honest responders, this design has no way to establish the prevalence rate o f malingering among different groups, the identification of malingering in each group or the divergence in performance between malingering and honest persons. Even if predicted differences are found, the differences cannot be related to malingering because of the nature of this design (Rogers). Each of these designs has methodological limitations and advantages. The primary strength of simulation design is its well controlled experimental manipulation o f response styles and systematic comparisons among criterion groups (Rogers, 1997). However, the disadvantage is its generalizability to real world populations. A strength of known groups comparison is its generalizability. Differential prevalence design is a relatively recent design and is methodologically a poor substitute for known groups comparison (Rogers). Overall, simulation design is the design that has been used most commonly for research on dissimulation. There are many tests and strategies that have been developed to help psychologists properly determine if an individual is malingering. Feigned cognitive impairment does not require the generation of believable symptoms. Instead, people who malinger intellectual or neuropsychological impairment may just put forward suboptimal effort with an appearance of sincerity (Rogers, 1997). Therefore, different strategies are recommended for detection o f cognitive or intellectual impairment. Measures o f Malingering Several tests designed to detect malingering can be subsumed under the general term. Symptom Validity Testing (SVT). This procedure was first described by Brady and Lind (1961) and modified by Pankratz, Fausti, and Peed (1975) as a means o f assessing the

17 Juvenile TOMM 8 validity of a variety of symptoms and complaints. Although the content of the procedure varies depending on the complaint to be evaluated, this procedure uses a two alternative, forced choice procedure. Initially used in the detection of sensory and motor deficits, it has been successfully used in the assessments o f memory complaints (Binder & Pankratz, 1987; Pankratz, 1983; Pankratz et al.). In applying SVT to questions of malingering of functional complaints, it is important to focus on the problems presented by the patients themselves. The clinician selects a reproducible stimulus for which the patient claims a deficit and this stimulus is then presented over a large number o f trials. For example, a patient reporting a short term memory deficit can be tested by being presented with one of two similar visual or auditory stimuli, such as colored lights or four or five digit numbers. Then the participant should perform a very brief intervening task, such as a repetitive task or counting backwards for three seconds, before reporting which stimulus they remember. Even if patients insist they cannot perform the task at all, they can be required to make the 100 choices. Because the procedure uses a two alternative, forced choice method, the expected hit rate of responses should be at least 50% (chance) (Pankratz, 1988). Pankratz reasoned that a performance of less than 50% could be used as an indication of malingering. The examiner reports to patients whether the choice was correct after each trial and this may cause patients to get the impression that they are doing much better than they thought they could when half the time they hear they are correct (Lezak, 1995). This procedure confronts malingering patients directly because it is difficult for patients to maintain a properly randomized response pattern that will result in a score within the range o f chance for 100 trials. SVT has its limitations. One critique is that positive findings indicate a problem is present, but negative findings do not rule out the problem (Lezak, 1995). That is, a

18 Juvenile TOMM 9 person s SVT score may be above 50%, but he or she may still be malingering. This points out the importance of using a variety of measures of malingering when evaluating patients and that it is important to be cautious when interpreting test results. The increased development and use of SVT procedures in the past decade (e.g., Hiscock Forced Choice Procedure, Portland Digit Recognition Test, Recognition Memory Test) has led to concerns over the capability of sophisticated or coached malingerers to detect these tasks and modify their performance so as to appear motivationally normal (Yoimgjohn, Lees-Haley & Binder, 1999). Youngjohn (1995) reported on a Worker s Compensation case in which a claimant and the claimant s attorney admitted that the attorney coached the claimant on a test of malingering. Wetter and Corrigan (1995) reported that almost 50% of practicing attorneys and 33% of the law students they surveyed believed that clients referred for psychological testing should be informed that the psychological tests they complete include validity scales. Effort can also be evaluated through identification of patterns of performance on standard neuropsychological tests. This approach is useful for correct identification of those cases o f malingering where a examinee, through sophistication or coaching, identifies the SVT s and performs normally on them (Larrabee, 2003). For example, malingerers have been detected by patterns of abnormally poor performance on measures of recognition memory (Millis, 1992; Millis, Putnam, Adams & Ricker, 1995), atypical errors on problem solving tasks (Suhr & Boyer, 1999), poorer gross compared to fine motor testing (Grieffenstein, Baker & Go la, 1996), abnormally poor attention on Digit Span performance relative to memory and Vocabulary (Mittenberg, Azrin, Millsaps, & Heilbronner, 1993; Mittenberg, Theroux-Fichera, Zielinski & Heilbronner, 1995), and poorer motor strength and speed, psychomotor skills, attention and sensory findings relative to other

19 Juvenile TOMM 10 neuropsychological functions (Heaton et al., 1978). These findings suggest that standard test procedures particularly sensitive to poor effort are tests of motor speed, attention, recognition memory, and problem solving. In addition, procedures for identification of poor effort on standard neuropsychological tests provide a means of evaluating the validity of previously administered neuropsychological evaluation in which SVT s were not used (Larrabee). Since the early 1990 s there has been an explosion in the number and types of measures designed to assess malingering, effort and response style. Lezak (1995) describes twenty different measures of malingering, although many of them are not widely researched. Below is a presentation of seven of the most widely researched measures of malingered memory complaints. Hiscock Forced Choice Procedure (HFCP) Hiscock et al. (1989) designed a two alternative forced choice digit recognition procedure to apply symptom validity testing to memory complaints. This test requires examinees to identify which of two five digit numbers shown on a card is the same as a number seen prior to a brief delay. Each of eight target numbers differs by two digits or more from its distracter number, including either the first or last digit. As a result, the actual memory requirements for the task are quite low, although the task appears to be difficult. Three sets of 24 trials have delays of 5, 10 and 15 seconds, consecutively for 72 trials. Feedback about performance is given after each response and patients are told that it is a memory test. Before beginning the second and third trial sets with the longer delays, the examiner tells the examinee that because he or she has done so well the test will be made more difficult (Lezak, 1995). Guilmette et al. (1993) found that actual brain damaged individuals performed significantly better than individuals asked to malinger, but only 34%

20 Juvenile TOMM 11 of the simulating group produced below chance performance. They suggested changing the cutoff for suspicion o f malingering to 90% correct and doing so resulted in correct identification of 90% of both the brain damaged and simulating groups. In a subsequent study, Guilmette, Hart, Guiliano & Leininger (1994) shortened the Hiscock test to 36 items (3 sets of 12 each with 5, 10 and 15 second delays) and found that the 90% correct criterion for detection of malingering resulted in correct identification o f all brain damaged subjects and 90% of simulators, rates that were comparable with the longer version. The shortened version has a 15 minute administration time. This test has its limitations as well. As found by Guilmette et al. (1993) and Guilmette et al. (1994), a percentage of those individuals asked to simulate brain damage obtain scores above the 90% cutoff, and therefore are not correctly identified. Post-test interviews of these subjects indicate that they correctly perceive the test as too easy, even for individuals with memory impairment. Another study by Guilmette, Whelihan, Hart, Sparadeo, & Buongiomo (1996) found that performance on the HFCP may be subject to the order in which it is presented in the test battery. When presented first, correct identification of malingering was significantly higher (65%) than when presented as the last measure in a battery of memory tests (35%), most likely due to the examinee s perception o f the test s relative difficulty. Portland Digit Recognition Test (PDRT) Another measure that is based on the symptom validity procedure is the PDRT (Binder, 1993a). Unlike the HFCP, the PDRT incorporates a series of distraction procedures into the interval between presentation and recall. The PDRT consists o f 72 items in which the examiner verbally presents a five digit number at the rate of one digit per second. The examinee is then instructed to count backward aloud until a recognition

21 Juvenile TOMM 12 probe card with the forced choice alternatives is presented. The numbers are printed one above the other on a card with the target position varied randomly. This differs from the administration of the HFCP not only in its auditory presentation, but because the time intervals are longer and the examinee engages in a distracting exercise before the recognition trial. They are 5 and 15 second delays for the first two blocks of 18 trials and 30 second delays for the last two blocks of 18 trials. Across all the sets, the delay interval is increased by having the examinee coimt backward from 20 (5 s, Set 1), 50 (15 s. Set 2), and 100 (30 s. Sets 3 and 4). Binder and Willis (1991) found that individuals not seeking financial compensation performed better on the PDRT than those seeking compensation related to an injury or condition. In a subsequent study (Binder, 1993b), 33% of a group of mild head trauma patients with compensation claims obtained PDRT scores that fell below any o f the three cutting scores (19 correct for the Easy set, 18 correct for the Hard set and 39 correct for the test as a whole), but only 17% performed below chance levels. This test provides a good, objective measure of motivation, but the PDRT was found to correlate significantly with performance on some neuropsychological measures and may measure divided attention and recent memory, as well as motivation (Binder et al., 1991). Binder et al. also noted that some individuals asked to simulate cognitive impairment do not produce scores within the range that raises suspicion of poor motivation. Therefore, a negative result on the PDRT does not rule out malingering and motivation should be assessed with a battery of measures. The PDRT has been criticized for the length of its administration time (it can take as long as an hour) and its failure to provide information about the examinee s neuropsychological status. Lezak (1995) feels that examinees, after performing their best on all the other tests, may become annoyed with the measure because they feel it is boring or an insult to their intelligence.

22 Juvenile TOMM 13 These problems may be alleviated by using a shortened procedure for examinees whose responses to the 36 easy items give no reason for the examiner to suspect their motivation (Binder, 1993c). The test can be discontinued for examinees who get 7 of 7 or 7 of 8 of the first 9 items correct on 30 second delay trials. Research on the classification agreement between the standard and abbreviated forms of the PDRT suggest that both forms are equivalent in detection rates o f malingering patients (Doane, Greve, & Bianchini, 2005; Gunstad & Suhr, 2004). Doane et al. report a classification agreement as high as 99.5% and state that using the abbreviated form will result in early termination in 60% of the patients, at a risk of missing 2% of patients who would have failed the standard form. The inclusion of other forced choice symptom validity tests in the battery will likely eliminate this risk. The abbreviated form o f the PDRT produces a 50% reduction in PDRT testing time, which is beneficial to well motivated patients who will not be burdened by the length of the test (Doane et al., 2005). Overall, the PDRT can be used in clinical settings without concern for false negative errors if it is not used in isolation. Recognition Memory Test (RMT) Although designed as a memory test, the RMT (Warrington, 1984) is a forced choice test that can be used as a symptom validity test. Millis (1992) used the RMT as a means o f detecting malingering by comparing mild head trauma patients seeking financial compensation to a group of more seriously injured patients who were not seeking financial settlement. This test examines recognition of words and faces separately thus measuring verbal and visual recognition memory. Using Warrington s norms, Millis found that 50% of the moderately to severely injured patients performances fell below the 54^' percentile on both parts of the test. In contrast, 90% o f the claimants obtained scores this low on the verbal (words) portion, whereas 78% were below the 5^ percentile on the nonverbal (faces)

23 Juvenile TOMM 14 portion. Twenty-five and 10% of the moderately to severely injured group performed above the 50^ percentile on words and faces, respectively, but none of the claimant group achieved scores that high (Lezak, 1995). It is important to note that as difficulty of the task increases, the score for nonmalingering patients may decline to chance level. It may be difficult to distinguish malingered performance from true impairment and more research on this measure is needed. Rey Fifteen Item Test (FIT) Unlike the previously described measures, the FIT does not use a SVT procedure. The FIT is among the earliest measures used to detect malingering (Rey, 1964). The principle underlying the FIT is that individuals who consciously or unconsciously wish to appear impaired will fail at a task that all but the most severely brain damaged or retarded patients perform easily. The task is presented as a test requiring memorization of 15 different items in a ten second time period. In the instructions, the number 75 is stressed to make the test appear to be more difficult than it is. The examinee is then asked to reproduce as many items as possible on a sheet of paper. In reality, the redundancy of the items [A B C, 1 2 3, a b c, O,, A, III, III] makes the memory requirement o f the measure fairly low (Lezak, 1995). There are various problems with the FIT. Some empirical investigations of the FIT indicate the measure may be sensitive to actual cognitive impairment, thus resulting in false positive identifications of malingering (Bernard, 1990; Guilmette et al., 1994). There is also not a clearly established cutoff score to identify feigned impairment. Goldberg and Miller (1986) used the 15 item format with acutely disturbed psychiatric patients and with people with mental retardation. All of the psychiatric patients recalled nine or more items, therefore suggesting a cutoff score o f fewer than nine items. Bernard et al. (1990)

24 Juvenile TOMM 15 also suggest a cutoff score of eight is reasonable based on their data on brain damaged patients. This cutoff score has been criticized as too nonspecific for persons with true impairment. Lee et al. (1992) recommended using a cutoff score of fewer than eight items reproduced, despite only a small gain in specificity for doing so (95% instead of 93%). Hays, Emmons and Lawson (1993) recommended interpretation of FIT scores with respect to IQ levels, failing to consider the possibility participants had feigned their IQ test performance. Others have considered the cutoff score of eight to be too nonspecific (Guilmette et al., 1994). Overall, Lezak (1995) has claimed that the FIT is popularly used due to the ease of administration and scoring, but it has not been well validated. Victoria Symptom Validity Test (VSVT) The VSVT (Slick et al., 1997) is a computer administered and scored, two alternative, forced choice symptom validity test designed to assess the validity o f a patient s reported cognitive impairments. It involves presenting a number of forced choice decisions to a patient to assess the presence or severity of reported cognitive impairments. The examinee is told that the test is assessing memory and that it requires concentration. The test is comprised of 48 items, presented in three blocks of 16 items each. A five digit study number is presented on a computer screen during the Study Trial for each item administered and then is followed by the Retention Trial in which a blank screen is shown. A Recognition Trial is presented in which two five digit numbers are presented on the computer screen, one of which was shown initially in the Study Trial, and the second number serves as a foil. The patient is asked to identify which o f the two five digit numbers were shown during the study trial by pressing a key on the right or left side of the computer s keyboard (Slick et al.).

25 Juvenile TOMM 16 The VSVT uses a number o f techniques to increase its sensitivity to detecting response bias by increasing the perceived difficulty of the test without increasing the actual difficulty of the test. The VSVT is different from other symptom validity tests in that it includes a third classification category. Questionable, to enhance its sensitivity while minimally affecting its specificity. This allows the clinician to rule out random responding with a higher degree of certainty (Thompson, 2002). When the examinee obtains scores that fall significantly above or below chance levels, they are classified as Valid or Invalid, respectively. Scores that are around chanee level are highly infrequent among outpatients with even moderate to severe head injuries who are not seeking compensation (Slick, Hopp, Strauss & Spellacy, 1996). Scores in this range are Questionable. In addition to computer administration and scoring, the VSVT prints out a six page report of all calculated values as well as interpretive statements about these values. A number of studies have demonstrated the VSVT s ability to identify response bias or malingering. Grote, Kooker, Garon, Nyenhuis, Smith & Mattingly (2000) found that two-thirds of their compensation seeking patients correctly answered fewer than 90% of the VSVT Difficult Items. Doss, Chelune & Naugle (1999) found that a high proportion of their compensation seeking patients performed in the Questionable and Invalid ranges on the VSVT. These studies demonstrate the utility o f this measure. Validity Indicator Profile (VIP) The VIP is a measure of effort that is used to identify malingering and other problematic response styles (Frederick, 1997). This test is a two alternative, forced choice measure of response validity that is intended to be administered as part of a battery of cognitive tests. The VIP was designed to identify compliant, careless, irrelevant and malingering response styles. The VIP modified the SVT procedure by establishing a

26 Juvenile TOMM 17 hierarchy of difficulty across the items presented. A performance curve representing average correct responses by average item difficulty is generated, demonstrating the average performance o f the test taker across an increasingly difficult range of test items (Frederick & Crosby, 2000). The expected progression of performance is from 100% correct for easy items to 50% correct for very difficult items. This results in a performance curve with a standard shape for compliant test takers across a broad range of capacity to answer correctly. The VIP consists of two subtests that are administered and scored separately. The VIP nonverbal subtest presents 100 picture matrix problems that require simple matching, complex matching, analogous decision making, progression, addition, subtraction and abstraction. The VIP verbal subtest consists of 78 word definition problems. Test takers are presented with a stimulus word and are asked to choose one of two possible answers that are more similar in meaning to the stimulus. For both subtests, the items have a hierarchy of difficulty but are presented randomly with respect to item difficulty. Once administered, the items are scored and then re-ordered by difficulty. The VIP requires computer scoring which can render it inefficient. A criticism of the VIP is that conclusions that examinees have feigned aspects of their presentation or exaggerated their impairments may be disguised by the VIP results of Careless or Irrelevant (Youngjohn et al., 1999). In addition, there has been a limited amount of research on this measure. Test o f Memory Malingering (TOMM) In the past decade, the TOMM (Tombaugh, 1996) has become a widely used and researched measure. The TOMM has been found to discriminate between truly memory impaired patients and malingerers (Tombaugh, 1997). It uses pictures o f common objects

27 Juvenile TOMM 18 and does not require reading, making it potentially suitable for a broad age range and ability range. The TOMM is a 50 item, two alternative, forced choice, symptom validity test of visual recognition memory. The test includes two learning trials and a retention trial. During the two learning trials, the examinee is shown 50 line drawings (target pictures) of common objects for three seconds each, at one second intervals. The subject is then shown 50 recognition panels, one at a time. Each panel contains one of the previously presented target pictures and a new picture (Tombaugh, 1996). The subject is required to select the previously seen picture. Explicit feedback on response correctness is given on each item. Different foils are used with the target items on the second recognition trial. The two learning trials alone provide information about feigned performance, but there is an optional retention trial about 15 minutes after Trial 2 and this is typically given only if the examinee gives more than five incorrect responses on Trial 2 in order to corroborate the results (Tombaugh). Several characteristics make the TOMM effective for detecting malingering or poor effort. The administration of a large number of visual stimuli gives the impression that the test is much more difficult than it really is. This allows malingerers to believe the test would be difficult for people with genuine memory impairments and intentionally perform poorly, whereas patients who exert their best effort perform well (Tombaugh, 1996). The TOMM also has good face validity as a test of learning and memory, which increases its effectiveness in detecting exaggerated or deliberately faked memory impairment. Lastly, feedback to patients on response correctness after each item widens the gap between the scores of memory impaired patients and malingerers. Feedback provides a learning opportunity between Trials 1 and 2 for motivated patients and should increase their

28 Juvenile TOMM 19 response accuracy on subsequent trials, while it allows malingerers to more accurately track their performance and adjust it accordingly (Tombaugh). While the TOMM is sensitive to malingering, it is relatively insensitive to neurological impairments. Individuals with many neurological impairments perform with high accuracy on this task. The TOMM also has the advantage of uncomplicated scoring; one point is given for each correct answer on the Recognition and Retention Trials. The minimum score on each trial is 0, and the maximum score is 50 (Tombaugh, 1996). The TOMM is not intended to be the only instrument of clinical assessment or a substitute for sound clinical judgment that utilizes various sources of information such as observation and clinical interviews. A high number of errors on the TOMM suggests memory impairment symptoms are false or exaggerated. A diagnosis o f malingering must also demonstrate that this exaggeration of symptoms was intentionally produced and motivated by external incentives (Tombaugh, 1996). Therefore, the TOMM offers a reliable, economical and useful first step in judging whether a patient is malingering. The TOMM has been studied using a number o f different populations including individuals with cognitive impairments, such as dementia (Teichner & Wagner, 2004; Tombaugh, 1997), psychotic disorders (Duncan, 2005), temporal lobe epilepsy (Hill, Ryan, Kennedy & Malamot, 2003), traumatic brain injuries (Gavett, O'Bryant, Fisher & McAffrey, 2005; Greve & Bianchini, 2006; Haber & Fitchenberg, 2006; Lynch, 2004; McAffrey, O Bryant & Fisher, 2003; Moore & Bonders, 2004; Rees, Tombaugh, Gansler & Moczynski, 1998;), affective disorders (Ashendorf, Constaninou & McAffrey, 2004; Rees, Tombaugh, & Boulay, 2001; Yanez, Fremouw, Tennant, Strunk & Coker, 2006), and with non head injury disability claimants (Gervais, Rohling, Green & Ford, 2004), electrical injury patients (Bianchini, Love, Greve, & Adams, 2005), individuals

29 Juvenile TOMM 20 experiencing laboratory induced pain (Etherton, Bianchini, Greve & Ciota, 2005), individuals exposed to environmental and industrial toxins (Greve, Bianchini, Black, Heinly, Love, Swift & Ciota, 2006), individuals involved with the legal system (Delain, Stafford & Ben-Porath, 2003; Gierok, Dickson & Cole, 2005; Heinze & Purisch, 2001; Tombaugh, 2002; Weinbom, Orr, Woods, Conover & Feix, 2003) and individuals asked to feign memory impairment (Brennan & Gouvier, 2006; Powell, Gfeller, Hendricks & Sharland, 2004; Tan, Slick, Strauss & Huksch, 2002). Appendix I provides a table summarizing the results o f these studies. Several studies have found that the majority of adults with genuine cerebral dysfunction perform with high accuracy on this instrument (Gavett et al., 2005; Greve et al., 2005; Haber et al., 2006; Hill et al., 2003; Lynch, 2004; McAffrey et al., 2003; Moore et al, 2004; Rees et al, 1998; Teichner et al., 2004; Tombaugh, 1997). In addition, poor performance on this test cannot be explained by psychiatric disorder (Ashendorf et al., 2004; Rees et al., 2001; Weinbom et al., 2003; Yanez et al., 2006). Overall, it has been very useful in identifying those with the highest risk to distort performance from those performing honestly. The TOMM has also been used in the legal setting with claimants for disability assessments or personal injury assessments (Gervais et al., 2004) and with persons being evaluated for competency to stand trial, not guilty by reason of insanity or civil commitment (Delain et al., 2003; Gierok et al., 2005; Heinze et al., 2001 ; Weinbom et al., 2003). These studies found that the majority of adults involved with the legal system perform with high accuracy on the TOMM. It is also important to note that individuals with dementia perform with less accuracy on the TOMM as compared to other groups of individuals (Teichner et al., 2004; Tombaugh, 1997). In a study by Tombaugh, the group of individuals with dementia performed with 92% accuracy on the second trial o f the TOMM,

30 Juvenile TOMM 21 while other groups of individuals (e.g., no cognitive impairment, with cognitive impairment, aphasia, TBI) performed with 97% accuracy or more on the TOMM. There are no data available on the performance of individuals of limited intellectual functioning on the TOMM. Children and Malingering An important part of clinical assessment is a consideration of whether the client, irrespective of age, is responding in an honest and forthright manner and with good motivation and effort. This concern becomes even more relevant when assessing children who historically have been depicted as less than credible informants of their own thoughts, feelings and behaviors (Oldershaw & Bagby, 1997).Unlike with adults, developmental factors play a critical role in understanding children s presentation during clinical assessment. A primary consideration is whether very young children are developmentally capable o f intentional deception. In order for children to provide intentionally false statements about themselves or a situation, they must first recognize that their false statements can actually mislead others (Oldershaw et al., 1997). Once children acquire this concept of false belief, they must realize that in order to successfully lie they must convince another of the sincerity of the false statement. Lewis (1993) suggests that children s ability to deceive is a skill learned early, and these deceptive skills increase over the first 6 years of life. Lies told by very young children typically take the form of a simple denial ( No ) or misleading confirmation ( Yes ), whereas the lies of older children and adolescents are more sophisticated elaborations (Bussey, 1992). Given that many self report measures and interviews allow for simple yes-no responses, young children appear to be quite capable of misrepresenting themselves with little likelihood of being detected (Oldershaw et al., 1997).

31 Juvenile TOMM 22 In understanding malingering, clinicians must clearly identify the objectives underlying the choice to misrepresent the truth. Motives for malingering among adults include unwarranted compensation, avoidance of prosecution, and attainment of a desirable position (Oldershaw et al., 1997). For children, such tangible motivators may not be readily apparent and children may misrepresent themselves for less overt motivations, such as attention and approval. Past research has shown that even young children engage in deceptive actions and that such deceptive acts could go easily undetected in psychological and neuropsychological evaluations (Faust, Hart & Guilmette, 1988; Faust, Hart, Guilmette & Arkes, 1988). In these studies, child and adolescent subjects were asked to perform below their capabilities on neuropsychological testing; those test results were sent to a sample of neuropsychologists, along with fabricated histories. Three fourths of the respondents judged the cases to be abnormal, but no respondent suspected that the test scores were malingered. When clinicians assess children, the child often does not have an accurate understanding of the assessment procedures and their purpose. Oldershaw et al. (1997) suggest that greater effort must be expended when assessing children to understand their perceptions of the evaluation and its purpose. This appraisal of children s perceptions helps clinicians to understand potential motives to deceive, malinger or underperform. It is also important to remember that children may express whatever they believe adults will respond to positively, regardless of truthfulness (Oldershaw et al.). For example, if a child believes an adult examiner wants negative symptoms, he or she might describe such symptoms to satisfy the perceived adult expectation. The family context also plays an important role in assessing children. Since children are under the social control o f others in their environment (Mash & Terdal, 1988), their

32 Juvenile TOMM 23 actions are highly influenced by parents and others in authority. Certain family variables appear to be related to children s defensiveness in psychological assessments. For example, children are likely to be more defensive during assessments when they are raised in highly religious families (Francis, Lankshear & Pearson, 1989), have mothers who work outside the home or grow up in an environment characterized by parental rejection, inconsistent discipline, dishonesty, and parental pressure to perform (Makaremi, 1992). Most conclusions about a child s adjustment are based on multiple sources of information. Clinicians must recognize that issues o f malingering in the assessment of children include not only a child s self report, but also parental reports about the child, which may also be distorted (Goodnow, 1988). Child psychologists have paid little attention to response styles, and there are currently no measures of malingering, effort, or response style that have been developed for or normed on children or adolescents. Unlike adult measures, test developers appear to have made the assumption that children and adolescents will be forthcoming regarding their psychological functioning (Oldershaw et al., 1997). Clinicians should be concerned about the lack of systematic research on response styles with child and adolescent populations. One circumstance where youths may misrepresent themselves is evaluation in the context of delinquency matters. Just as with adult criminal defendants, the primary challenge with youths charged with delinquent acts is the respondent s truthfulness. In most jurisdictions youths involved in serious crimes can be charged as adults and tried in the adult court where dispositional penalties are far more severe than in the juvenile court; this could lead some juveniles to misrepresent themselves as less capable than they are in order

33 Juvenile TOMM 24 to be spared more serious consequences. Youths may also misrepresent themselves in order to be found not competent to stand trial. As children enter adolescence, their capacity for deception and misrepresentation is thought to increase. Adolescence is a developmental stage for working through a healthy awareness of the potency of human deceptive behavior (Hall & Poirier, 2001). It is also a developmental stage that can be characterized by an immature style of coping with life challenges through deception. Clinical and forensic assessment must involve examination of the adolescent s response styles o f appreciating, engaging in, and managing deceptive behavior. Many clinicians working with violent adolescent offenders and adolescent sexual offenders contend that these groups represent the extreme of the adolescent continuum with respect to potential for deception. When assessing juvenile delinquents and juvenile victims of abuse concerns about credibility, deception and malingering are important. Deceptive behavior with all age groups is influenced by situational variables that affect possible outcomes for the individual (Hall et al., 2001). The higher the motivation to achieve or avoid a specific outcome, the greater the likelihood of deception. The significant limitations of direct measures of deception and malingering on psychological tests, combined with the characteristic adolescent guardedness, require clinicians to rely on assessment information beyond the data itself (Hall et al.). Guilmette et al. (1988) asked 3 adolescents (15 to 17 years old) to feign impairment on a battery of neuropsychological tests and found that the adolescents were able to fool neuropsychologists who reviewed their test scores. Specifically, the adolescents convinced nearly 80% of the neuropsychologists that abnormalities were present, but malingering was never suspected.