Determining cutoff scores on the Conners' adult ADHD rating scales that can definitively rule out the presence of ADHD in a clinical sample.

In recent years, the prevalence of Attention Deficit/Hyperactivity Disorder (ADHD) and the number of individuals seeking ADHD assessments has risen significantly, leading to an increased demand for accurate diagnostic tools. This study aimed to identify cutoff scores on the Conners' Adult ADHD Rating Scales (CAARS-S:L) that can definitively rule out the presence of ADHD. Among 102 clinically diagnosed adult ADHD participants and 448 non-ADHD participants who completed the CAARS-S:L, a receiver operating characteristic curve analysis established a perfectly discriminant cutoff T-score of <44 on the ADHD Symptoms Total subscale when looking at any ADHD diagnosis and <54 on the Inattentive Symptoms subscale when looking at individuals diagnosed with the inattentive subtype of ADHD. Alternative cutoffs of <54 (ADHD Symptoms Total subscale) and <63 (Inattentive Symptoms subscale) were also identified, both with a sensitivity of 0.95 or higher. Furthermore, the analysis found the ADHD Index to be a poor predictor of a negative ADHD diagnosis, suggesting against the use of this scale for cutoff determination. Despite this limitation, these findings indicate that with specific cutoffs, the CAARS-S:L may have the potential to conclusively rule out ADHD, effectively streamlining the diagnostic process and reducing unnecessary comprehensive assessments in clear negative cases.

ADHD and Anxiety Symptoms: Does Construct or Assessment Type Matter More?

OBJECTIVE: This study examined the relationships between self-reported ADHD symptoms, self-reported anxiety, and continuous performance test (CPT) performance. METHOD: 128 postsecondary students referred for clinical evaluation for possible ADHD and related conditions completed the Conners Adult ADHD Rating Scale, the Behavior Assessment Scale for Children, Third Edition, and either of two CPTs. RESULTS: Multiple regression models found that when self-reported anxiety and CPT performance were used to simultaneously predict self-reported ADHD symptoms, CPT performance was not a significant predictor, whereas self-reported anxiety was. This finding was replicated across two different subsamples that took different CPTs. CONCLUSION: Self-reported anxiety and ADHD symptoms are strongly related, but neither of these variables is significantly related to CPT performance. Implications for clinical practice and future research are discussed.

The Ability of Self-Report Methods to Accurately Diagnose Attention Deficit Hyperactivity Disorder: A Systematic Review.

OBJECTIVE: To identify and analyze all studies validating rating scales or interview-based screeners commonly used to evaluate ADHD in adults. METHOD: A systematic literature search identified all studies providing diagnostic accuracy statistics, including sensitivity and specificity, supplemented by relevant articles or test manuals referenced in reviewed manuscripts. RESULTS: Only 20 published studies or manuals provided data regarding sensitivity and specificity when tasked with differentiating those with and without ADHD. While all screening measures have excellent ability to correctly classify non-ADHD individuals (with negative predictive values exceeding 96%), false positive rates were high. At best, positive predictive values in clinical samples reached 61%, but most fell below 20%. CONCLUSION: Clinicians cannot rely on scales alone to diagnose ADHD and must undertake more rigorous evaluation of clients who screen positive. Furthermore, relevant classification statistics must be included in publications to help clinicians make statistically defensible decisions. Otherwise, clinicians risk inappropriately diagnosing ADHD.

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.

Predictive value of performance validity testing and symptom validity testing in psychoeducational assessment.

Using archival data from 2463 psychoeducational assessments of postsecondary students we investigated whether failure on either symptom or performance validity tests (SVTs or PVTs) was associated with score differences on various cognitive, achievement, or executive functioning performance measures or on symptom report measures related to mental health or attention complaints. In total, 14.6% of students failed one or more PVT, 33.6% failed one or more SVT, and 41.6% failed at least one validity test. Individuals who failed SVTs tended to have the highest levels of self-reported symptoms relative to other groups but did not score worse on performance-based psychological tests. Those who failed PVTs scored worse on performance-based tests relative to other groups. Failure on at least one PVT and one SVT resulted in both performance and self-reported symptoms suggestive of greater impairment compared with those who passed all validity measures. Findings also highlight the need for domain-specific SVTs; failing ADHD SVTs was associated only with extreme reports of ADHD and executive functioning symptoms while failing mental health SVTs related only to extreme reports of mental health complaints. Results support using at least one PVT and one SVT in psychoeducational assessments to aid in diagnostic certainty, given the frequency of non-credible presentation in this population of postsecondary students.

Accommodation Decision-Making for Postsecondary Students with ADHD: Treating the Able as Disabled.

Students with attention-deficit/hyperactivity disorder (ADHD) may be entitled to academic accommodations in postsecondary education. Disability Services Offices (DSOs) in Canada say that objective evidence of functional impairment is required prior to providing academic accommodations. This study set out to determine if postsecondary disability service providers use objective, third-party data when making accommodation decisions. Providers were asked if they would grant extra time accommodations to a fictitious prospective student. The student self-reported attention and academic problems that emerged during COVID restrictions, and that extra time helped her earn better grades and reduced her anxiety. While her neuropsychological report suggested superficial similarity to ADHD and contained accommodation recommendations, it lacked any objective evidence supporting either an ADHD diagnosis or functional impairments that would support extra time accommodation. Despite the lack of current or historical functional impairment, 100% of all DSO decision makers confirmed that they would grant extra time accommodations to this student. Results suggest that DSOs' accommodation decisions are not based on evidence of functional impairment but rely mainly on student self-report and the recommendations of a professional. As such, the current system of determining reasonable accommodations is flawed and inequitable, offering non-impaired individuals access to supports and services that may privilege them over their similarly abled peers. Postsecondary institutions must either develop more defensible methods of disability determination or provide all students with access to accommodations to create a more equitable learning environment.

The impact of depression and anxiety on speed of academic performance and retrieval fluency in postsecondary students.

Objective: This study evaluated the functional effects of severe mental health symptoms on speed of academic performance to assist clinicians and educators in determining whether extra time accommodations are evidence-based for students with such diagnoses. Method: Using archival data from 1476 post-secondary students, we examined the performance of students with existing mental health diagnoses who were also reporting extremely high levels of symptoms. Their performance on timed academic achievement and cognitive processing measures was compared with performance of students with learning disabilities, Attention Deficit Hyperactivity Disorder, and clinical controls. Students failing stand-alone performance validity and/or symptom validity measures were excluded from this investigation. Results: Students diagnosed with anxiety and/or depression did not differ from clinical controls on any timed performance measure, typically performing academic tasks within a normal amount of time. By contrast, those with reading disabilities were typically the slowest on all academic tasks. Conclusion: Across the range of timed tests, students with mental health diagnoses did not show functional impairments in tests with a speed component. As such, they would not typically require increased time to perform speeded academic tasks, but they might require alternative accommodations in their post-secondary programmes in order to participate equally.

Processing speed and timed academic skills in children with learning problems.

Information processing speed is commonly measured in intelligence and neuropsychological testing, and the scores from speed measures are considered in diagnostic and management recommendations for students with academic learning problems. However, this score usage often depends on assumptions about strong relationships between cognitive speed and the ability to perform actual academic tasks under time pressure. The primary purpose of the present study was to test the strength of these relationships empirically. In the present study, children with prior learning disability diagnoses (146 girls and 301 boys, ages 10-14 years old) completed diagnostic batteries that included measures of cognitive speed as well as timed academic skills. The relationships between the two types of measures were often modest (median r = 0.25), and the gap between processing speed and timed academic scores was typically approximately 1 standard deviation. The pattern of relationships suggested that superficial similarity in stimuli and task demands affected the strength of associations. These results suggest that timed academic skills cannot be reliably estimated based on processing speed scores, and there will often be significant gaps between the two. Therefore, making diagnostic judgments (e.g., learning disability diagnoses) or management recommendations (e.g., for extended time testing accommodations) should be based on more direct measures of relevant academic skills.

Susceptibility of functional impairment ratings to noncredible reporting in postsecondary students undergoing screening for ADHD.

Objective: Clinical evaluation for attention-deficit/hyperactivity disorder (ADHD) not only requires assessment of symptoms, but also consideration of the degree to which symptoms lead to impairment within various functional domains. However, ADHD evaluations in adulthood often rely on self-reported functional impairment, which might be vulnerable to malingering/noncredible responding. The present study utilized a clinical sample/known groups design to examine the relationship of noncredible presentation to functional impairment ratings by analyzing differential associations with both symptom and performance validity tests (SVTs and PVTs). Method: Participants were 168 postsecondary students who completed psychoeducational assessments for ADHD to determine their eligibility for academic accommodations and/or medications. Impairment ratings on the Weiss Functional Impairment Rating Scale (WFIRS) of 71 students who presented in a noncredible fashion were compared to 72 students who appeared to present credibly (controls) and 25 students diagnosed with ADHD who appeared to present credibly (clinical controls). Results: Relative to both control groups, individuals who presented noncredibly reported higher levels of disability on most functional domains and a higher percentage provided responses that fell in the impaired range on all functional domains of the WFIRS. Conclusions: Findings provide additional evidence that ADHD-related functional impairment ratings are susceptible to noncredible presentation and highlight the need for assessors to include both SVTs and PVTs in ADHD evaluations.

Discriminating malingered attention Deficit Hyperactivity Disorder from genuine symptom reporting using novel Personality Assessment Inventory validity measures.

It is now widely understood that ADHD can be feigned easily and convincingly. Despite this, almost no methods exist to assist clinicians in identifying when such behavior occurs. Recently, new validity indicators specific to feigned ADHD were reported for the Personality Assessment Inventory (PAI). Derived from a logistic regression, these algorithms are said to have excellent specificity and good sensitivity in identifying feigned ADHD. However, these authors compared those with genuine ADHD only to nonclinical undergraduate students (asked to respond honestly or asked to simulate ADHD); no criterion group of definite malingerers was included. We therefore investigated these new validity indicators with 331 postsecondary students who underwent assessment for possible ADHD and compared scores of those who were eventually diagnosed with ADHD (n = 111) to those who were not [Clinical controls (66), Definite malingerers (36); No diagnosis (117)]. The two proposed PAI algorithms were found to have poor positive predictive value (.19 and .17). Self-report validity measures from the Connors' Adult Attention Rating Scale, and the Negative Impression Management scale on the PAI returned more positive results. Overall, more research is needed to better identify noncredible ADHD presentation, as the PAI-based methods proposed by Aita et al. appear inadequate as symptom validity measures.

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.

Learning disability documentation submitted by osteopathic medical students.

An increasing number of individuals are requesting disability accommodations on high-stakes licensing examinations, and neuropsychological evaluation reports are a frequent component of disability documentation. This study reviewed 103 requests for accommodations based on a learning disability (LD), submitted to the National Board of Osteopathic Medical Examiners between 2013 and 2016 for accommodation on the licensure exams for osteopathic physicians. Depending on criteria employed, anywhere from 84 to 97% of applicants failed to meet recognized criteria for a LD diagnosis, with the vast majority demonstrating academic functioning that was average or better relative to most other individuals in the general population. Thus, although given a disability diagnosis, the majority lacked evidence of substantial impairment that would require accommodations under the Americans with Disabilities Act. Additionally, no significant differences were found between the academic achievement or fluency scores of those requesting 50% as compared to 100% extra time. Finally, many evaluators employed grade-based assessment measures to demonstrate academic impairment, even when candidates' functioning using age-based comparisons was unimpaired. Recommendations for future research and practice based on these and other findings are discussed.

A comparison of the self-report patterns of analog versus real-world malingerers of attention deficit hyperactivity disorder.

Much of what we know about malingering of attention deficit hyperactivity disorder (ADHD) has been learned from the performance of analog malingerers, typically first-year psychology students given credit for study participation. It is not clear, however, whether their performance is similar to that found in actual clinical settings. Indeed, past research suggests that analog malingerers may overexaggerate deficits relative to real-world malingerers, making them easier to identify in controlled studies. The purpose of the current study was, therefore, to compare the performance of analog malingers to post-secondary students strongly suspected of malingering ADHD on a self-report measure of ADHD symptoms. Their scores were, in turn, compared to those returned by students with genuine ADHD and clinical controls. Results demonstrated that, apart from analog subjects overexaggerating symptoms of hyperactivity, few differences exist between the scores returned by analog malingerers relative to clinical malingerers. While newly devised symptom validity measures show promise in identifying malingered ADHD, neither the analog nor the clinical malingers consistently failed these symptom validity scales. Furthermore, a good portion in both malingering groups failed to endorse high levels of ADHD symptoms in general. Clinical implications are discussed.

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

Measuring performance validity in Attention Deficit Hyperactivity Disorder (ADHD) assessments is essential, with multiple studies identifying how easily young adults can feign symptoms on self-report measures. Few methods, however, exist to identify such feigning when it occurs. While some clinicians include computerized tests of attention (e.g., Test of Variables of Attention [TOVA]) when assessing for possible ADHD, it is unclear how symptom exaggerators perform, and whether the TOVA Symptom Exaggeration Index (SEI) adequately identifies performance-based exaggeration when it occurs. Using archival data from a university-based ADHD screening clinic we investigated the performance of 245 late adolescents/emerging adults. Three groups were created: (1) Good effort but not ADHD (n = 183); (2) Good effort and diagnosed ADHD (n = 13); and (3) suspect effort (n = 49), based on final diagnosis and performance on an existing validity measure. Results showed clearly that those with suspect effort performed more poorly than the other two groups on all but second-half commission errors on the TOVA. Similar to Nicholls et al., the suspect effort group showed significantly subaverage (i.e., greater than two standard deviations below the mean) scores in Omission errors; in this replication, however, this was true for both the first and second half of the test. Response time variability was similarly exaggerated, with the suspect effort group again returning extreme scores in both halves of the test. Suspect effort students were indistinguishable from those with genuine ADHD when looking solely at self-reported symptoms; however, embedded symptom validity measures on an ADHD rating scale discriminated well between groups. Overall, results support the use of the TOVA as an embedded performance validity measure in the assessment of late adolescents/emerging adults and support previous findings that symptom report alone cannot distinguish credible from noncredible ADHD presentation.

The license plate test performance in Canadian adolescents with learning disabilities: A preliminary study.

Accurate identification of symptom exaggeration is essential when determining whether data obtained in pediatric evaluations are valid or interpretable. Performance validity measures identify performance patterns that are implausible if the test taker is investing full effort; however, it is unclear whether or not persons with preexisting cognitive difficulties such as Specific Learning Disabilities (SLD) might be falsely accused of poor test motivation due to actual but impaired reading, processing or memory skills. The purpose of this study was to evaluate the newly developed License Plate Test (LPT) performance in students with identified SLD providing good effort, to examine the influence of severe reading or learning problems on LPT performance. Participants were 29 students with SLDs aged 11-14 years (M = 12.1), who completed psycho-educational assessments as part of a transition program to secondary school. Results indicate that recognition memory measures on the LPT were insensitive to cognitive impairments in these children; all students achieved scores of 80% or higher on these tasks. Performance was more variable as test demands of the LPT increased, and the difference between performance on easy and hard subtests was related to greater difficulties with working memory. These results provide preliminary data regarding how children with SLD perform on the LPT, allowing for development of appropriate cut scores to maximize sensitivity and specificity of this test for use with child and adolescent populations.

Diagnostic implications of the double deficit model for young adolescents with dyslexia.

Considerable support exists for both the phonological core deficit and the naming speed deficit models of dyslexia. The double deficit model proposed that many students with dyslexia might also be impaired in both underlying processes. Employing either performance thresholds (i.e., scores below the 16th or 25th percentile) or k-means clustering as classification methods, the current study investigated whether 154 young adolescents with dyslexia could be categorized into subtypes according to the presence or absence of phonological deficits alone, naming speed deficits alone, or a combination of the two and whether group composition changed depending on classification method. Results support the existence of both single and double deficit groups and confirm that those with both deficits are the most severely impaired across multiple measures. Contrary to previous research, most adolescents were classified as either naming speed only (about a third of the group) or double deficit when defining impairment using performance thresholds to classify groups. This may suggest that although early phonological deficits are amenable to remediation, identification of language symbols fails to become automatized in most individuals with dyslexia and may require more targeted intervention. Classification differences reported in the literature may depend on age and methods employed for classification.

Comparing Age- and Grade-Based Norms on the Woodcock-Johnson III Normative Update.

There has been a marked increase in accommodation requests from students with disabilities at both the postsecondary education level and on high-stakes examinations. As such, accurate identification and quantification of normative impairment is essential for equitable provision of accommodations. Considerable diversity currently exists in methods used to diagnose learning disabilities, including whether an impairment is normative or relative. This study investigated the impact on impairment classification if grade-based norms were used to interpret identical raw scores compared with age-based norms. Fourteen raw scores distributed equally across the adult range of the Woodcock-Johnson III Normative Update subtests were scored using norms for either age (18-29 years) or grade (13-17). The results indicate that raw scores receive a significantly lower standardized score (and thus percentile ranking) when grade-based norms are used. Furthermore, the difference between age- and grade-based scores increases dramatically as raw scores decrease, and there is a significant interaction between age and grade in the standard scores obtained. This study provides evidence to suggest that using different norms may result in different decisions about diagnoses and appropriate accommodations.

Comparison of the neurocognitive profiles of individuals with elevated psychotic or depressive symptoms.

AIM: Neurocognitive deficits are pervasive and enduring features of severe mental illness that appear before the onset of clinical symptoms and contribute to functional disability. However, it remains unclear how individuals who display warning signs for psychotic or mood disorders compare on their neurocognitive profiles since previous studies have separately examined neurocognition in both groups. Therefore, the purpose of this study was to directly compare performance on a range of neurocognitive tasks in individuals with emerging psychotic or mood symptoms. METHODS: Participants were drawn from a database of individuals who completed a comprehensive assessment at a university-based assessment centre. We examined 3 groups: individuals who endorsed elevated psychotic symptoms (EPS; n = 64), individuals who endorsed elevated depressive symptoms (EDS; n = 58), or non-clinical comparisons (NCC; n = 57) without any elevated psychiatric symptoms or diagnoses. RESULTS: EPS participants performed worse than NCC and EDS groups on verbal comprehension, working memory and cognitive flexibility, and worse than NCC, but not EDS, on perceptual reasoning. There were no significant differences between groups on processing speed, verbal fluency and set-shifting. EDS performed worse than both EPS and NCC groups on psychomotor speed. Dimensionally, poorer cognitive functioning was more strongly related to EPS than depressive symptoms. CONCLUSIONS: These findings highlight the distinct yet overlapping neurocognitive profiles of both groups with emerging psychiatric symptoms, and suggest that, despite having no formal diagnosis, individuals with EPS exhibit observable cognitive impairment and may still benefit from interventions within academic and workplace contexts.

Diagnostic Accuracy of the Conners' Adult ADHD Rating Scale in a Postsecondary Population.

Objective: Clinicians frequently rely upon the results of self-report rating scales when making the diagnosis of ADHD; however, little research exists regarding the ability of self-report measures to accurately differentiate ADHD from other disorders. Method: This present study investigated the ability of the Conners' Adult ADHD Rating Scale (CAARS) to discriminate between 249 postsecondary students with carefully diagnosed ADHD and 507 clinical controls. Results: The overall discriminant validity of the CAARS was 69%, and it had an unacceptably high false positive and false negative rate. At lower prevalence rates, a high score on the CAARS has only a 22% chance of accurately identifying individuals with ADHD. Conclusion: Although the CAARS is an adequate screening measure, it should not be the main method by which a diagnosis is made, as it frequently misidentifies individuals with other psychological complaints as having ADHD. Implications for clinical practice are discussed.