The Importance of the Morel Emotional Numbing Test Instructions: A Diagnosis Threat Induction Study.

OBJECTIVE: Marketed as a validity test that detects feigning of posttraumatic stress disorder (PTSD), the Morel Emotional Numbing Test for PTSD (MENT) instructs examinees that PTSD may negatively affect performance on the measure. This study explored the potential that MENT performance depends on inclusion of "PTSD" in its instructions and the nature of the MENT as a performance validity versus a symptom validity test (PVT/SVT). METHOD: 358 participants completed the MENT as a part of a clinical neuropsychological evaluation. Participants were either administered the MENT with the standard instructions (SIs) that referenced "PTSD" or revised instructions (RIs) that did not. Others were administered instructions that referenced "ADHD" rather than PTSD (AI). Comparisons were conducted on those who presented with concerns for potential traumatic-stress related symptoms (SI vs. RI-1) or attention deficit (AI vs. RI-2). RESULTS: Participants in either the SI or AI condition produced more MENT errors than those in their respective RI conditions. The relationship between MENT errors and other S/PVTs was significantly stronger in the SI: RI-1 comparison, such that errors correlated with self-reported trauma-related symptoms in the SI but not RI-1 condition. MENT failure also predicted PVT failure at nearly four times the rate of SVT failure. CONCLUSIONS: Findings suggest that the MENT relies on overt reference to PTSD in its instructions, which is linked to the growing body of literature on "diagnosis threat" effects. The MENT may be considered a measure of suggestibility. Ethical considerations are discussed, as are the construct(s) measured by PVTs versus SVTs.

The Behavior Rating Inventory of Executive Function®-Adult Version is Related to Emotional Distress, Not Executive Dysfunction, in a Veteran Sample.

OBJECTIVE: In three studies, we explore the impact of response bias, symptom validity, and psychological factors on the self-report form of the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) and the relationship between self-reported executive functioning (EF) and objective performance. METHOD: Each study pulled from a sample of 123 veterans who were administered a BRIEF-A and Minnesota Multiphasic Personality Inventory-2 (MMPI-2) during a neuropsychological evaluation. Participants were primarily middle-aged, and half carried a mood disorder diagnosis. Study 1 examined group differences in BRIEF-A ratings among valid, invalid, and indeterminate MMPI-2 responders. Analyses were conducted to determine the optimal cut-score for the BRIEF-A Negativity Validity scale. In Study 2, relationships were explored among MMPI-2-RF (restructured form) Restructured Clinical (RC) scales, somatic/cognitive scales, and the BRIEF-A Metacognition Index (MI); hierarchical analyses were performed to predict MI using MMPI-2-RF Demoralization (RCd) and specific RC scales. Study 3 correlated BRIEF-A clinical scales and indices with RCd and an EF composite score from neuropsychological testing. Hierarchical analyses were conducted to predict BRIEF-A clinical scales. RESULTS: Invalid performance on the MMPI-2 resulted in significantly elevated scores on the BRIEF-A compared to those with valid responding. A more stringent cut-score of ≥4 for the BRIEF-A Negativity scale is more effective at identifying invalid symptom reporting. The BRIEF-A MI is most strongly correlated with demoralization. BRIEF-A indices and scales are largely unrelated to objective EF performance. CONCLUSIONS: In a veteran sample, responses on the BRIEF-A are most representative of generalized emotional distress and response bias, not actual EF abilities.

Education and Training for Clinical Neuropsychologists in Integrated Care Settings.

The increasing importance of integrated care necessitates that education and training experiences prepare clinical neuropsychologists for competent practice in integrated care settings, which includes (a) general competence related to an integrated/interdisciplinary approach and (b) competence specific to the setting. Formal neuropsychology training prepares neuropsychologists with a wide range of knowledge and skills in assessment, intervention, teaching/supervision, and research that are relevant to such settings. However, less attention has been paid to the knowledge and skills that directly address functioning within integrated teams, such as the ability to develop, maintain, and expand collaboration across disciplines, bidirectional clinical-research translation and implementation in integrated team settings, and how such collaboration contributes to clinical and research activities. Foundational knowledge and skills relevant to interdisciplinary systems have been articulated as part of competencies for entry into clinical neuropsychology, but their emphasis in education and training programs is unclear. Recommendations and resources are provided regarding how competencies relevant to integrated care can be provided across the continuum of education and training (i.e., doctoral, internship, postdoctoral, and post-licensure).

Taxonomy for Education and Training in Clinical Neuropsychology: past, present, and future.

OBJECTIVE: Historically, the clinical neuropsychology training community has not clearly or consistently defined education or training opportunities. The lack of consistency has limited students' and trainees' ability to accurately assess and compare the intensity of neuropsychology-specific training provided by programs. To address these issues and produce greater 'truth in advertising' across programs, CNS, with SCN's Education Advisory Committee (EAC), ADECN, AITCN, and APPCN constructed a specialty-specific taxonomy, namely, the Taxonomy for Education and Training in Clinical Neuropsychology. The taxonomy provides consensus in the description of training offered by doctoral, internship, and postdoctoral programs, as well as at the post-licensure stage. Although the CNS approved the taxonomy in February 2015, many programs have not adopted its language. Increased awareness of the taxonomy and the reasons behind its development and structure, as well as its potential benefits, are warranted. METHODS: In 2016, a working group of clinical neuropsychologists from the EAC and APPCN, all authors of this manuscript, was created and tasked with disseminating information about the taxonomy. Group members held regular conference calls, leading to the generation of this manuscript. RESULTS: This manuscript is the primary byproduct of the working group. Its purpose is to (1) outline the history behind the development of the taxonomy, (2) detail its structure and utility, (3) address the expected impact of its adoption, and (4) call for its adoption across training programs. CONCLUSIONS: This manuscript outlines the development and structure of the clinical neuropsychology taxonomy and addresses the need for its adoption across training programs.

Validity testing and neuropsychology practice in the VA healthcare system: results from recent practitioner survey (.).

OBJECTIVE: A survey of neuropsychologists in the Veterans Health Administration examined symptom/performance validity test (SPVT) practices and estimated base rates for patient response bias. METHOD: Invitations were emailed to 387 psychologists employed within the Veterans Affairs (VA), identified as likely practicing neuropsychologists, resulting in 172 respondents (44.4% response rate). Practice areas varied, with 72% at least partially practicing in general neuropsychology clinics and 43% conducting VA disability exams. RESULTS: Mean estimated failure rates were 23.0% for clinical outpatient, 12.9% for inpatient, and 39.4% for disability exams. Failure rates were the highest for mTBI and PTSD referrals. Failure rates were positively correlated with the number of cases seen and frequency and number of SPVT use. Respondents disagreed regarding whether one (45%) or two (47%) failures are required to establish patient response bias, with those administering more measures employing the more stringent criterion. Frequency of the use of specific SPVTs is reported. CONCLUSIONS: Base rate estimates for SPVT failure in VA disability exams are comparable to those in other medicolegal settings. However, failure in routine clinical exams is much higher in the VA than in other settings, possibly reflecting the hybrid nature of the VA's role in both healthcare and disability determination. Generally speaking, VA neuropsychologists use SPVTs frequently and eschew pejorative terms to describe their failure. Practitioners who require only one SPVT failure to establish response bias may overclassify patients. Those who use few or no SPVTs may fail to identify response bias. Additional clinical and theoretical implications are discussed.

The Times They Are a Changin': Neuropsychology and Integrated Care Teams.

OBJECTIVE: To gather illustrative data from clinical neuropsychologists who are working in integrated care settings in order to provide an initial blueprint for moving forward in this new era of health care. METHOD: A survey was designed to illustrate the ways in which neuropsychologists are participating in integrated care teams and distributed on major neuropsychology listservs. The survey evaluated the settings, roles, services provided, practice issues, remuneration, and impact of neuropsychologists' participation in integrated care teams with respect to patient care and health outcomes. Frequencies were used to summarize the findings as well as qualitative coding of narrative responses. RESULTS: There were 412 respondents to the survey and 261 of those indicated that they worked in at least one integrated care setting. Neuropsychologists work in a variety of integrated care settings and provide diverse services which contribute to improved patient care and outcomes. CONCLUSIONS: Three primary themes emerge from the findings with regard to the engagement and teams: advocacy, collaboration, and communication. We argue for the need for more easily accessible outcome studies illustrating the clinical benefits and cost-savings associated with inclusion of neuropsychologists in integrated care teams. In addition, educational and training initiatives are needed to better equip current and future clinical neuropsychologists to function effectively in integrated care settings.

Verbal Fluency: Language or Executive Function Measure?

Measures of phonemic and semantic verbal fluency, such as FAS and Animal Fluency (Benton, Hamsher, & Sivan, 1989), are often thought to be measures of executive functioning (EF). However, some studies (Henry & Crawford, 2004a , 2004b , 2004c ) have noted there is also a language component to these tasks. The current exploratory factor-analytic study examined the underlying cognitive structure of verbal fluency. Participants were administered language and EF measures, including the Controlled Oral Word Association Test (FAS version), Animal Fluency, Boston Naming Test (BNT), Vocabulary (Wechsler Adult Intelligence Scale-III), Wisconsin Card-Sorting Test (WCST, perseverative responses), and Trail-Making Test-Part B (TMT-B). A 2-factor solution was found with the 1st factor, language, having significant loadings for BNT and Vocabulary, while the second factor was labeled EF because of significant loading from the WCST and TMT-B. Surprisingly, FAS and Animal Fluency loaded exclusively on to the language factor and not EF. The current results do not exclude EF as a determinant of verbal fluency, but they do suggest that language processing is the critical component for this task, even without significant aphasic symptoms. Thus, the results indicated that both letter (phonemic) and category (semantic) fluency are related to language, but the relationship to EF is not supported by the results.

Staying on the job: The relationship between work performance and cognition in individuals diagnosed with multiple sclerosis.

People with multiple sclerosis (MS) are apt to become unemployed as the disease progresses, and most research implies that this is due to diminishing mobility. Some studies have shown that presence of cognitive impairment also predicts employment status. Yet, no studies have examined how neuropsychological factors predict vocational performance among individuals with MS who remain employed. We assessed employer- and self-rated work performance, mobility status, and neuropsychological function in a sample of 44 individuals diagnosed with MS. Results suggest that cognitive impairment is common in these employed individuals, despite largely intact mobility status. Moreover, a significant interaction emerged, such that cognitively impaired individuals' work performance was rated more poorly by supervisors. In contrast, self-ratings of work performance were higher in cognitively impaired than in unimpaired participants. These novel findings suggest that cognitive impairment may influence work performance, even in patients whose physical disability status is relatively intact.

Language-based embedded performance validity measures in traumatic brain injury.

No studies to date have investigated the Boston Naming Test (BNT) as an embedded performance validity test (PVT). This study investigated the classification accuracy of the Boston Naming Test (BNT) and the Verbal Fluency Test (FAS and Animal Fluency), as embedded PVTs in a compensation-seeking mild traumatic brain injury (MTBI) sample (N = 57) compared to a non-compensation-seeking moderate-to-severe TBI (STBI) sample (N = 61). Participants in the MTBI sample who failed two or more PVTs were included, as were STBI participants who passed all PVTs. The classification accuracy of the individual tests and a logistically derived combined (LANGPVT) measure were studied. Results showed significant group differences (p < .05) on BNT, Animal Fluency, and LANGPVT between the MTBI and STBI groups. However, receiver operating characteristic (ROC) analyses indicated that only LANGPVT had acceptable classification accuracy (area under the curve > .70). Setting specificity at approximately .90, the recommended LANGPVT cutoff scores had sensitivity of .26. Results indicated that, similar to other embedded PVTs, these measures had low sensitivity when adequate specificity levels were maintained. However, extremely low scores on these measures are unlikely to occur in non-compensation-seeking, non-language-impaired, STBI cases.

[Formula: see text]Official Position of the American Academy of Clinical Neuropsychology (AACN): Guidelines for Practicum Training in Clinical Neuropsychology.

Practical experience is central to the education and training of neuropsychologists, beginning in graduate school and extending through postdoctoral fellowship. However, historically, little attention has been given to the structure and requirements of practicum training in clinical neuropsychology. A working group of senior-level neuropsychologists, as well as a current postdoctoral fellow, all from a diverse range of settings (The AACN Practicum Guidelines Workgroup), was formed to propose guidelines for practicum training in clinical neuropsychology. The Workgroup reviewed relevant literature and sought input from professional organizations involved in education and training in neuropsychology. The proposed guidelines provide a definition of practicum training in clinical neuropsychology, detail entry and exit criteria across competencies relevant to practicum training in clinical neuropsychology, and discuss the relationship between doctoral training programs and practicum training sites. The proposed guidelines also provide a methodology for competency-based evaluation of clinical neuropsychology practicum trainees and outline characteristics and features that are integral to an effective training environment. Although the guidelines discussed below may not be implemented in their entirety across all clinical neuropsychology practicum training sites, they are consistent with the latest developments in competency-based education.

Supervision in neuropsychological assessment: a survey of training, practices, and perspectives of supervisors.

Within the psychology supervision literature, most theoretical models and practices pertain to general clinical or counseling psychology. Supervision specific to clinical neuropsychology has garnered little attention. This survey study explores supervision training, practices, and perspectives of neuropsychology supervisors. Practicing neuropsychologists were invited to participate in an online survey via listservs and email lists. Of 451 respondents, 382 provided supervision to students, interns, and/or fellows in settings such as VA medical centers (37%), university medical centers (35%), and private practice (15%). Most supervisors (84%) reported supervision was discussed in graduate school "minimally" or "not at all." Although 67% completed informal didactics or received continuing education in supervision, only 27% reported receiving training specific to neuropsychology supervision. Notably, only 39% were satisfied with their training in providing supervision and 77% indicated they would likely participate in training in providing supervision, if available at professional conferences. Results indicate that clinical neuropsychology as a specialty has paid scant attention to developing supervision models and explicit training in supervision skills. We recommend that the specialty develop models of supervision for neuropsychological practice, supervision standards and competencies, training methods in provision of supervision, and benchmark measures for supervision competencies.

Are verbal intelligence subtests and reading measures immune to non-credible effort?

The validity of neuropsychological testing is reliant on examinees putting forth adequate effort, yet it has been asserted that verbal subtests from the Wechsler Adult Intelligence Scales (WAIS) are insensitive to suboptimal effort in comparison to other commonly used neuropsychological measures. The current study examined performance differences on the entire WAIS-IV and WRAT-4 Reading, as well as the CVLT-II and several WMS-IV subtests, in 207 Veterans classified into Credible Effort (n = 146) and Non-credible Effort (n = 61) groups. Analyses revealed that the Non-credible Effort group performed significantly lower on all examined measures including verbal tests, with moderate to large effect sizes observed for most tests. Current findings thus indicate that WAIS-IV verbal subtests and reading ability measures, such as on the WRAT-4, are not insensitive to effects of non-credible effort. Consequently it is recommended that these tests not generally be used to estimate baseline intellectual functioning when found in the presence of non-credible effort. While there was broad performance suppression across all measures examined, results also showed a distinct continuum of test susceptibility with some measures being more or less sensitive to inadequate effort. Recommendations for future performance validity test development are presented.

Postdoctoral recruitment in neuropsychology: a review and call for inter-organizational action.

The history of centralized matches for postgraduate selection is briefly discussed with a focus on the match instituted by the Association of Postdoctoral Programs in Clinical Neuropsychology (APPCN) in 2001] Survey data, conducted both by APPCN and independently, are summarized. In general, despite incomplete participation and an estimated 30% rate of "exploding offers", applicants are somewhat satisfied with the match according to recent surveys (although satisfaction varies depending on whether an applicant matched). Given the high rate of withdrawal, the history of other specialties with suboptimal participation, and the concerns most commonly expressed by participants about this issue in survey data, there is cause for concern. We assert that incomplete participation in the match hurts applicants and programs. We propose that focused efforts are needed involving multiple organizations to enhance the match, including the Clinical Neuropsychology Synarchy (CNS) as our specialty council and the multiple organizations represented on the CNS.

Validation of the repeatable battery for the assessment of neuropsychological status--effort index in a veteran sample.

The RBANS Effort Index (RBANS-EI; Silverberg, Wertheimer, & Fichtenberg, 2007) is an embedded measure of effort within a frequently employed neuropsychological screening battery. While it has been criticized for inadequate specificity in older non-litigating samples (Hook, Marquine, & Hoelzle, 2009; Warren et al., 2010), the RBANS-EI has yet to be investigated in a non-geriatric veteran sample. Archival data were collected from 85 veterans who completed the RBANS and WMT within either a routine neuropsychological evaluation (n = 66) or compensation evaluation (n = 19). At a cutoff of >3 RBANS-EI exhibited strong specificity (.94) yet limited sensitivity (.31) in the prediction of WMT performance. Examination of RBANS-EI component subtests found that List Recognition <17 had strong specificity (.90) and moderate sensitivity (.52) in discriminating WMT performance groups. In contrast, Digit Span performance was comparable between those passing and failing the WMT. Present findings indicate that both the RBANS-EI and List Recognition subtest may be useful in detecting suboptimal effort yet raise questions regarding the Digit Span component of the RBANS-EI.

Expansion and re-examination of Digit Span effort indices on the WAIS-IV.

The Digit Span subtest was significantly revised for the WAIS-IV as an ordinal sequencing trial was added to increase working memory demands. The present investigation sought to validate an expanded version of Reliable Digit Span (RDS-R) as well as age-corrected scaled score (ACSS) from the recently revised Digit Span. Archival data were collected from 259 veterans completing the WAIS-IV Digit Span subtest and Word Memory Test (WMT). Veterans failing the WMT performed significantly worse (p < .001) on the ACSS, RDS-R, and traditional RDS. Operational characteristics of the ACSS, RDS-R, and RDS were essentially equivalent; however, sensitivity was quite modest when selecting cutoffs with strong specificity. While current results suggest that Digit Span effort indices can contribute to the detection of suboptimal effort, additional symptom validity indicators should be employed to compensate for limited sensitivity.

Validation of the MMPI-2 Response Bias Scale and Henry-Heilbronner Index in a U.S. veteran population.

The Response Bias Scale (RBS) and the Henry-Heilbronner Index (HHI) are two recently developed Minnesota Multiphasic Personality Inventory-2 (MMPI-2) validity scales empirically derived for the purpose of detecting feigned symptom report. Utilizing a veteran sample, the present study examined the utility of these and other MMPI-2 validity scales in predicting Word Memory Test (WMT) failure and presence of recent, current, or upcoming compensation evaluation. Although a significant predictor of WMT performance, RBS did not show incremental validity over Infrequency scale of the MMPI-2 in prediction of WMT failure and was not significantly associated with membership in the "Compensation-Context" (CC) group. In contrast, HHI best predicted CC group membership, but only trended toward significance in predicting WMT failure. In predicting CC group membership, HHI showed incremental validity above the established MMPI-2 validity scales, but its specificity was low. In the context of current literature on RBS and HHI, results support continued use of RBS and HHI but suggest that these scales may perform differently in samples other than the compensation-seeking samples on which they were developed.

Ascorbic acid does not influence consciousness recovery after anesthesia.

Several studies have examined the influence of general anesthesia on changes in consciousness and unconscious cognitive processes. However, much remains to be learned about potential moderators of general anesthetic agents, such as antioxidants including ascorbic acid, and their influence on the recovery of consciousness following general anesthesia. General anesthesia potentially affects plasma ascorbic acid levels and may impair consciousness during the postoperative period; however, published literature regarding these relationships is equivocal. Ascorbic acid is important for brain function and may be related to the return of postoperative consciousness through action on the synaptic receptors in the brain. This study was designed as a pretest-posttest repeated measures investigation. Ascorbic acid levels were measured at four time periods in patients (N = 50) undergoing surgery and general anesthesia. Following surgery, patients were administered a paper-and-pencil measure of concentration that served as an index of post-anesthesia consciousness. The results suggest that changes occur in plasma ascorbic acid levels at different time points during the anesthesia regimen in nonemergent surgical patients. No statistically significant relationships were found between plasma ascorbic acid levels and improved post-anesthesia consciousness, suggesting that ascorbic acid does not influence recovery of consciousness following general anesthesia.

Admission intervention team: medical center based intensive case management of the seriously mentally ill.

The purpose of this study was to investigate the effect a medical center based intensive case management team had on utilization of inpatient psychiatric treatment. A frequent user of inpatient psychiatric hospitalization was defined as any patient who had 3 or more admissions during the 12 months prior to referral to the program. A within-subjects design was used comparing rates of hospital admissions and hospital days before and after program enrollment for 185 patients in the program for 1 year, and for 50 of those patients in the program for 7 years. Cost savings across program years 1992 through 2000 were calculated using inpatient per diem rates. The number of admissions, length of stay, and cost of care were significantly reduced during the study period. The results of this study clearly demonstrate that a medical center based intensive case management team can significantly reduce admissions, length of stay, and the cost of care of frequent users of hospital inpatient services. Development of a true multidisciplinary team, enhancement of medication and treatment compliance, and a team case management model were the factors suggested as contributing to the success of this treatment program.