Multidimensional Malingering Criteria for Neuropsychological Assessment: A 20-Year Update of the Malingered Neuropsychological Dysfunction Criteria.

OBJECTIVES: Empirically informed neuropsychological opinion is critical for determining whether cognitive deficits and symptoms are legitimate, particularly in settings where there are significant external incentives for successful malingering. The Slick, Sherman, and Iversion (1999) criteria for malingered neurocognitive dysfunction (MND) are considered a major milestone in the field's operationalization of neurocognitive malingering and have strongly influenced the development of malingering detection methods, including serving as the criterion of malingering in the validation of several performance validity tests (PVTs) and symptom validity tests (SVTs) (Slick, D.J., Sherman, E.M.S., & Iverson, G. L. (1999). Diagnostic criteria for malingered neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical Neuropsychologist, 13(4), 545-561). However, the MND criteria are long overdue for revision to address advances in malingering research and to address limitations identified by experts in the field. METHOD: The MND criteria were critically reviewed, updated with reference to research on malingering, and expanded to address other forms of malingering pertinent to neuropsychological evaluation such as exaggeration of self-reported somatic and psychiatric symptoms. RESULTS: The new proposed criteria simplify diagnostic categories, expand and clarify external incentives, more clearly define the role of compelling inconsistencies, address issues concerning PVTs and SVTs (i.e., number administered, false positives, and redundancy), better define the role of SVTs and of marked discrepancies indicative of malingering, and most importantly, clearly define exclusionary criteria based on the last two decades of research on malingering in neuropsychology. Lastly, the new criteria provide specifiers to better describe clinical presentations for use in neuropsychological assessment. CONCLUSIONS: The proposed multidimensional malingering criteria that define cognitive, somatic, and psychiatric malingering for use in neuropsychological assessment are presented.

On percentile norms in neuropsychology: proposed reporting standards and methods for quantifying the uncertainty over the percentile ranks of test scores.

Normative data for neuropsychological tests are often presented in the form of percentiles. One problem when using percentile norms stems from uncertainty over the definitional formula for a percentile. (There are three co-existing definitions and these can produce substantially different results.) A second uncertainty stems from the use of a normative sample to estimate the standing of a raw score in the normative population. This uncertainty is unavoidable but its extent can be captured using methods developed in the present paper. A set of reporting standards for the presentation of percentile norms in neuropsychology is proposed. An accompanying computer program (available to download) implements these standards and generates tables of point and interval estimates of percentile ranks for new or existing normative data.

Quality of life and seizure outcome after vagus nerve stimulation in children with intractable epilepsy.

This study examined the effect of vagus nerve stimulation on quality of life in children with epilepsy using a validated quality-of-life scale and an empirical technique that accounts for measurement error in assessing individual change (the reliable change index). Participants were 34 children with severe intractable epilepsy who underwent vagus nerve stimulation and 19 children with intractable epilepsy who received medical management. Parent-completed epilepsy-specific and global ratings at baseline and after 1 year indicated that most children had no changes in quality of life following vagus nerve stimulation (52%-77%), similar to the comparison group. There was a trend for decreases to be less common in the vagus nerve stimulation group (14% vs 37%, P < .07), but there was no relation between improved quality of life and seizure control. The results raise questions about the mechanisms that underlie changes in quality of life after vagus nerve stimulation in this group of children.

Sociodemographic correlates of health-related quality of life in pediatric epilepsy.

In most chronic conditions, better health-related quality of life (HRQOL) is associated with higher socioeconomic status (SES) and ethnic majority status, with disadvantaged groups typically reporting lower HRQOL. In 163 children with intractable epilepsy, we evaluated the relationship between HRQOL and a broad spectrum of demographic variables (SES, parental education, gender, age, marital status, family size, and ethnic and linguistic status), in relation to known neurological and behavioral correlates of HRQOL. No demographic variable was found to be related to child HRQOL, except for marital status, where children from divorced/separated parents had lower HRQOL. However, marital status was not uniquely predictive of HRQOL when neurological and behavioral variables were taken into account. Exploratory analyses indicated that children of separated/divorced parents were more likely to have early epilepsy onset, lower adaptive/developmental levels, and worse seizure frequency, suggesting that severe epilepsy may be a risk factor for marital stress. In sum, contrary to research in other chronic conditions, sociodemographic variables in pediatric epilepsy were weak predictors of HRQOL in comparison to neurological and behavioral variables. The results are discussed with respect to epilepsy-specific determinants of HRQOL.

ADHD, neurological correlates and health-related quality of life in severe pediatric epilepsy.

PURPOSE: ADHD is reported as a frequent comorbidity in pediatric epilepsy. We aimed to clarify the prevalence of ADHD, its neurological correlates and the role of ADHD in health-related quality of life (HRQOL) in children with severe epilepsy. METHOD: Data from the ADHD Rating Scale-IV (ADHD-RS-IV) from 203 children (mean age = 11.8, SD=3.8) from a tertiary center serving children with severe epilepsy were reviewed. RESULTS: Inattention was frequently elevated in the sample (40% vs. 18% for hyperactivity-impulsivity). Age of onset, epilepsy duration, and seizure frequency were not related to severity of inattention or hyperactivity-impulsivity. Over 60% of children met screening criteria for ADHD-Inattentive subtype (ADHD-I) or ADHD-Combined Inattentive/Hyperactive-Impulsive subtype (ADHD-C). Compared to ADHD-I, ADHD-C was associated with earlier onset of seizures, generalized epilepsy, lower adaptive level, and in normally developing children, a higher degree of intractability compared to ADHD-I. ADHD-I was more prevalent in localization-related epilepsy, and there was a trend for a higher use of AEDs with cognitive side effects in this group. ADHD was associated with poor HRQOL: children with ADHD-I and ADHD-C had a two- and four-fold likelihood of low HRQOL, respectively, compared to non-ADHD children. CONCLUSIONS: Children seen at tertiary care centers for severe epilepsy are at high risk for attention problems and ADHD, and ADHD is a significant predictor of poor HRQOL in epilepsy, particularly in the case of ADHD-C. ADHD occurring in the context of severe epilepsy appears to be associated with specific neurological characteristics, which has implications for comorbidity models of ADHD and epilepsy.

Postsurgical health-related quality of life (HRQOL) in children following hemispherectomy for intractable epilepsy.

Health-related quality of life (HRQOL) is an important outcome measure in clinical research. Given the psychosocial and behavioral difficulties associated with pediatric epilepsy, evaluating HRQOL in this patient population is of particular importance. Though HRQOL has been examined in pediatric patients receiving focal resection or pharmacological (antiepileptic drug; AED) treatment, it has not been assessed in patients receiving hemispherectomy (HE) for intractable epilepsy. The current study evaluated HRQOL in a sample of pediatric HE cases (N=26) using previously validated questionnaires relative to surgical (N=30) and nonsurgical (N=84) comparison groups. Compared with focal resection and nonsurgical patients, parents of children who received HE reported similar levels of HRQOL. In surgical cases, worse HRQOL was correlated with residual seizure frequency. In both surgical and nonsurgical cases, female gender, higher AED load, and lower functional independence predicted worse HRQOL. Interestingly, HE status (i.e., having undergone HE) predicted fewer epilepsy-related limitations. Consistent with previous findings, AED load, in addition to lower functional abilities, appear particularly detrimental to life quality in pediatric epilepsy. HE, however, is not associated with increased risk for poor HRQOL. When considered in light of the multiple, significant risk factors for poor outcome associated with HE, children who undergo the procedure fare surprisingly well.

Executive dysfunction is a significant predictor of poor quality of life in children with epilepsy.

PURPOSE: Based on prior research indicating poor health-related quality of life (HRQOL) in children with attention-deficit/hyperactivity disorder, we investigated (1) whether executive functioning deficits were related to poor HRQOL in children with epilepsy, (2) how important these variables were in comparison to known predictors of HRQOL such as neurological factors, and (3) the extent to which clinical-level impairments in executive dysfunction predispose children to low HRQOL. METHOD: Data included scores on the Behavior Rating Inventory of Executive Function (BRIEF) and HRQOL scales (The Impact of Childhood Illness Scale [ICI] and Hague Restrictions in Epilepsy Scale [HARCES]) for 121 children (mean age = 11.9, SD = 3.6) from a tertiary center serving children with severe epilepsy. RESULTS: Correlations between the BRIEF and ICI total and subscore domains (child, parent, family, and treatment) were generally significant and moderate (e.g., r > or = 0.30, p < or = 0.001). BRIEF Global Executive Composite, number of antiepileptic drugs (AEDs), number of prior AEDs, and adaptive level all emerged as significant and unique predictors of HRQOL (R(2)= 0.36, adj. R(2)= 0.33, p < 0.0001). A clinically elevated BRIEF was associated with a twofold risk of low HRQOL (odds ratio = 2.21, p = 0.03). CONCLUSIONS: Executive dysfunction appears to exert a broad adverse influence on HRQOL in children with epilepsy, with clinical-level impairments in executive dysfunction contributing to a twofold increase in the likelihood of poor HRQOL. The constellation of executive dysfunction, low adaptive level, high medication load, and a history of several failed AEDs are risk factors for poor HRQOL in children with epilepsy.

Frequency of scale elevations and factor structure of the Behavior Rating Inventory of Executive Function (BRIEF) in children and adolescents with intractable epilepsy.

The Behavior Rating Inventory of Executive Function (BRIEF) is a standardized rating scale that provides information about the nature and extent of executive function deficits displayed by children and adolescents in daily life. BRIEF protocols completed by parents of 80 children with intractable epilepsy were evaluated with respect to prevalence and severity of scale elevations in the sample, and also with respect to factor structure. Overall, the sample was rated as having significantly more executive function problems than healthy children in the BRIEF standardization sample; elevations on the Working Memory and Plan/Organize scales were most frequently seen. Fully 36% of the sample had four or more significantly elevated scales. However, 31% of the sample had no clinically elevated scales, indicating that executive difficulties, though frequent, are not necessarily characteristic of all children with severe epilepsy. As in the validation studies reported in the manual, a two-factor solution emerged from a principal factor analysis of BRIEF scales. However, the factor structure as given in the manual was not entirely replicated; specifically, the Monitor scale was found to load equivalently on both factors. The results of this study suggest that a substantial proportion of children with intractable epilepsy display significant executive function deficits in daily life. Research into the relationship of BRIEF scores to other measures of executive functioning in children with epilepsy is needed to further clarify its clinical utility.

The factor structure of the CVLT-C in pediatric epilepsy.

The current study used archival data to evaluate the fit of six latent variable models, originally generated by Donders (1999), for the California Verbal Learning Test-Children's Version (CVLT-C; Delis, Kramer, Kaplan, & Ober, 1994) in a large (N = 289) sample of pediatric epilepsy cases presenting at three tertiary treatment centers. Using confirmatory factor analysis, we found that a model including factors of Attention Span, Learning Efficiency, Free Delayed Recall, Cued Delayed Recall, and Inaccurate Recall demonstrated the best relative fit for our data. These findings are consistent with those reported by Donders (1999) in his reanalysis of the CVLT-C standardization sample data, supporting the validity of this factorial model in pediatric epilepsy populations.

Detecting malingering: a survey of experts' practices.

A survey addressing practices of 'expert' neuropsychologists in handling financial compensation claim or personal injury litigation cases was carried out. Potential participants were identified by publication history. Responses were obtained from 24 out of the 39 neuropsychologists who were surveyed. Approximately 79% of the respondents reported using at least one specialized technique for detecting malingering in every litigant assessment. Half stated that they always give specialized tests at the beginning of the assessment. The Rey 15-Item test and the Test of Memory Malingering were the most frequently reported measures. Respondents also reported frequent use of 'malingering' indexes from standard neuropsychological tests. Reported base-rates varied, but the majority of respondents indicated that at least 10% of the litigants they assessed in the last year were definitely malingering. Respondents were split on the practice of routinely giving warnings at the outset of assessments that suboptimal performance may be detected. However, when the client's motivational status was suspect, more than half (58.3%) altered their assessment routine at least on some occasions, by encouraging good effort (70.8%) or administering additional SVTs. A minority directly confronted or warned clients (25%), terminated the examination earlier than planned (16.6%), or contacted the referring attorney immediately (29.2%). Respondents almost always stated some opinion regarding indicators of invalidity in written reports (95%). However, 41.7% rarely used the term 'malingering' and 12.5% never used the term. Most respondents (>80%) instead stated that the test results are invalid, inconsistent with the severity of the injury or indicative of exaggeration.

Reexamining the effects of epilepsy surgery on IQ in children: use of regression-based change scores.

Prior studies have found no adverse effects of pediatric epilepsy surgery on IQ. However, empirical techniques such as regression models, designed to account for confounding factors such as practice effects and test-retest reliability and able to provide a standardized method for evaluating outcome, have not been used in studying change after pediatric epilepsy. The goal of this study was to demonstrate the regression technique while empirically measuring the effect of epilepsy surgery on IQ in a group of pediatric patients. Predictors of retest IQ (e.g., baseline IQ, retest interval, demographics, epilepsy severity) were evaluated in a control group with intractable seizures (N = 23) assessed twice with the WISC-III. The resulting equation was used to evaluate IQ changes in a second group of children who underwent epilepsy surgery (N = 22). In controls, baseline IQ was a strong predictor of retest IQ. Number of AEDs was inversely related to retest IQ. Based on the control regression, four children (18%) in the surgical sample obtained significantly higher than expected postsurgical IQ scores and one child (5%) obtained a lower than expected IQ score. This study demonstrates that regression-based techniques yield informative estimates on outcome and may be an improvement over prior methods of measuring change after pediatric epilepsy surgery.

Victoria Symptom Validity Test scores of patients with profound memory impairment: nonlitigants case studies.

Victoria Symptom Validity Test (VSVT) scores from six nonlitigants with neurological illness accompanied by dense anterograde amnesia or severe memory impairment are presented. All of these patients obtained perfect or near perfect scores on the VSVT. These data add to the literature suggesting that the VSVT is insensitive to genuine neurologically-based memory impairment and provide an additional floor-level clinical benchmark against which to compare the performance of litigants.

Validity of three measures of health-related quality of life in children with intractable epilepsy.

PURPOSE: Validity studies on health-related quality of life (HRQOL) scales for pediatric epilepsy are few, and cross-validation with other samples has not been reported. This study was designed to assess the validity of three parent-rated measures of HRQOL in pediatric epilepsy: (a) the Impact of Childhood Illness Scale (ICI), (b) the Impact of Child Neurologic Handicap Scale (ICNH), and (c) the Hague Restrictions in Epilepsy Scale (HARCES). METHODS: Retrospective data were examined for 44 children with intractable epilepsy. Validity was assessed by evaluating differences across epilepsy severity groups as well as correlations between HRQOL scales and neurologic variables (seizure severity, epilepsy duration, current/prior antiepileptic medications) and psychosocial measures (emotional functioning, IQ, social skills, adaptive behavior). Scale overlap with a global QOL rating also was assessed. RESULTS: The HRQOL measures were moderately to highly intercorrelated. The scales differed in terms of their associations with criterion measures. The HARCES was related to the highest number of neurologic variables and the ICNH to the fewest. All three scales were related to psychosocial functioning and to global quality of life. CONCLUSIONS: The results of this study suggest that the three measures are likely adequate measures of HRQOL for use in intractable childhood epilepsy. The measures were highly intercorrelated, and they were all broadly related to criterion measures reflecting specific domains of HRQOL as well as global QOL. Some differences between scales emerged, however, that suggest care in choosing HRQOL instruments for children with epilepsy.

Intraindividual variability as an indicator of malingering in head injury.

The utility of various measures of malingering was evaluated using an analog design in which half the participants (composed of three groups: naive healthy people, professionals working with head-injured people, individuals who suffered a head injury but not currently in litigation) were asked to try their best and the remainder was asked to feign believable injury. Participants were assessed with the Reliable Digit Span (RDS) task, the Victoria Symptom Validity Test (VSVT), and the Computerized Dot Counting Test (CDCT) on three separate occasions in order to determine whether repeat administration of tests improves prediction. The results indicated that regardless of an individual's experience, consideration of both level of performance (particularly on forced-choice symptom validity tasks) and intraindividual variability holds considerable promise for the detection of malingering.

How'd they do it? Malingering strategies on symptom validity tests.

Twenty-five undergraduate students were instructed to feign believable impairment following a brain injury from a car accident and 27 students were told to perform like they had recovered from such an injury. Three forced-choice tests, the Test of Memory Malingering (TOMM), Victoria Symptom Validity Test (VSVT), and Word Memory Test (WMT) were given. Test-taking strategies were evaluated by means of a questionnaire given at the end of the test session. The results revealed that all the tasks differentiated between groups. Using conventional cut-scores, the WMT proved most efficient while the VSVT captured the most participants in the definitive below-chance category. Individuals instructed to feign injury were more likely to prepare prior to the experiment, with feigning of memory loss as the most frequently reported strategy. Regardless, preparation effort did not translate into believable performance on the tests.