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By Expert ID: SC853, Psy.D.

Despite general agreement on the importance of symptom validity assessment in medico-legal contexts, the issue as a necessary practice in the examination of college students who show signs of Attention-Deficit/Hyperactivity Disorder (ADHD) was, until 2007, almost entirely neglected. Clinicians had no guidance as to whether (and if so, to what extent), symptom exaggeration might occur in that population, potentially in the interest of malingering. However, a ground-breaking study by this author and his colleagues appearing in Applied Neuropsychology  initiated an end to that neglect, with dismaying results.

Motivated by potentially attractive benefits associated with diagnoses of ADHD or learning disorders (LDs), adults undergoing diagnostic evaluations for these disorders might exaggerate symptomatology on self-report measures and tests of neurocognitive functioning. Of concern is the fact that student adults who might wish to present themselves as impaired by these disorders face considerable secondary gain potentials that might be perceived as offering academic advantages. These include academic accommodations (e.g., extended test time, private testing environments, alternative courses) and other forms of assistance available to impaired students as provided for by the Individuals with Disabilities Act (IDEA) of 1975, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act (ADA) of 1990. A diagnosis of ADHD carries additional secondary gain potential in the form of psychostimulant medications commonly prescribed as treatment for the condition. Unfortunately, these medications have a history of misuse, abuse, and distribution in college students.

Researchers only rarely have recommended specific procedures for the objective assessment of negative response bias in adult ADHD or LD evaluations, whether regarding the validity of self-report questionnaire responses or performance on neurocognitive measures. However, prior to our study, no data had been reported regarding the use of such SVTs among college or university student adults seeking assessment of possible ADHD or LD. Furthermore, given that few, if any, available self-report symptom inventories for ADHD in adults include methods for identification of negative response bias (i.e., over-reporting), we believed that an external criterion in the form of assessment of effort on neurocognitive performance measures would be the best starting point to establish estimates of symptom exaggeration in this population.

One such measure, the Word Memory Test, is designed to detect suboptimal effort in the context of neuropsychological evaluations. Students’ performances on this measure, in the context of actual (not analogue) assessments, were a focus of our study. Examining our data via several empirical hypotheses, our results suggest that significant numbers of college students demonstrate poor effort in the context of ADHD and LD evaluations, and that such poor effort is an indication of symptom magnification motivated by secondary gain potentials.

Using the WMT, arguably the most sensitive SVT available in neuropsychological assessments, we found high rates of symptom exaggeration as evidenced by suboptimal effort exertion in ADHD assessments. Those rates were 24.5% when ADHD and LD were assessed concurrently, and 47.6% when ADHD was the sole target disorder assessed.

As a preliminary indication, it appears reasonable that the base rate for symptom exaggeration among college students self-referred for ADHD evaluations might be estimated at approximately 25–48%, with a possible gender-by-evaluation-type interaction. This estimate is comparable to the 25% figure offered by Binder as a general base rate for symptom exaggeration in neuropsychological assessments, as well as the 30% rate found by Constantinou, Bauer, Ashendorf, Fisher, and McCaffrey when examining other populations.

Post hoc analyses revealed that the rates at which the ADHD examinees reported the nature and severity of their symptoms differed significantly between the WMT passers and failers.  The ADHD evaluation patients who failed the WMT produced consistently higher Conners Adult ADHD Rating Scale Long Version scores than did the WMT passers on each of the major CAARS indices. The findings of inverse correlations between WMT performance and self report ADHD symptom levels, as well as significant mean score differences, is quite noteworthy as perhaps the strongest of our evidence that WMT failure is an indication of symptom exaggeration and not simply suboptimal effort on performance measures.

These data suggest that clinicians’ reliance upon self-report questionnaires in the absence of neurocognitive performance measures and performance-based SVTs like the WMT is ill-advised as regards sensitivity to symptom exaggeration. Of course, this also speaks to the importance of clinicians’ examination of multiple sources of data, including those garnered by a thorough developmental and academic history.

Clinicians who rely on neurocognitive and/or intellectual capacity measures in ADHD and LD assessments without concurrent assessment of the effort the examinees are exerting toward their performances, will be insufficiently sensitive to rates of exaggerated symptomatology that can rival, or even exceed those in forensic settings, where secondary gain potentials are arguably more obvious. In particular, clinicians who rely upon self-report measures in the absence of performance-based symptom validity measures are probably risking far more false positives than they suspect. Our evidence suggests that examination of negative response bias indices within other, concurrently-administered measures of co-morbidity is probably of little help in the detection of symptom exaggeration in this population. This study even calls into question the validity of available self-report measures of adult ADHD symptomatology, to the degree that test developers included diagnosed college students in their standardization processes.

These findings will likely not only surprise but also dismay administrators and disabilities support staff within higher education institutions. However, they would do well to seriously consider these data in their critical reviews of ADHD and LD assessments conducted within or submitted to their campus departments in applications for academic accommodations. That symptom exaggeration in ADHD and LD assessment happens at all is noteworthy, given the implications for misdirection of institutional finances devoted to disability support programs on campuses. Greater concern arises from the misuse, abuse, and inappropriate distribution of controlled substances, including psychostimulants. For that reason, prescribing clinicians should also heed these data so as to heighten their awareness of the vital importance of valid data in their own assessments and in their reviews of other clinicians.

By Expert ID: SC853, Psy.D.