Noncredible Effort during Pediatric Neuropsychological Exam: A Case Series and Literature Review

Neuropsychological test interpretation rests upon the assumption that the examinee has exerted full effort. If an individual provides inadequate effort during exam, the resulting data will be invalid and represent an underestimate of the person's true abilities. Although youth have been assumed historically to be less capable of deception than adults, acts of deception in childhood are not uncommon, even in normative populations. Yet, very few cases of children who have provided suboptimal effort during neuropsychological exam have appeared in the scientific literature. We present six clinical cases illustrating that children down to at least age 8 years can present with noncredible performance. The cases include those in which clear external incentives could be identified to those in which intrinsic or psychological factors were presumed to predominate. The fairly diverse nature of the presented cases, along with other recent work, suggests that suboptimal effort in children is apt to occur more frequently than previously recognized, even if it might occur less often than in comparable adult samples. In most of the presented cases, noncredible performance would not have been detected definitively by clinical judgment alone, reinforcing the value of routinely incorporating symptom validity tests into the neuropsychological assessment of school-aged children. The number of effort tests that have demonstrated utility in children pales in comparison to those available to the adult practitioner, although recent research now supports the use of several standalone measures with pediatric patients.     

Wisconsin Card Sorting Test embedded validity indicators developed for adults can be extended to children

Past studies have examined the ability of the Wisconsin Card Sorting Test (WCST) to discriminate valid from invalid performance in adults using both individual embedded validity indicators (EVIs) and multivariate approaches. This study is designed to investigate whether the two most stable of these indicators—failures to maintain set (FMS) and the logistical regression equation S-B_LRE—can be extended to pediatric populations.

The classification accuracy for FMS and S-B_LRE was examined in a mixed clinical sample of 226 children aged 7 to 17 years (64.6% male, MAge = 13.6 years) against a combination of established performance validity tests (PVTs).

The results show that at adult cutoffs, FMS and S-B_LRE produce an unacceptably high failure rate (33.2% and 45.6%) and low specificity (.55–.72), but an upward adjustment in cutoffs significantly improves classification accuracy. Defining Pass as <2 and Fail as ≥4 on FMS results in consistently good specificity (.89–.92) but low and variable sensitivity (.00–.33). Similarly, cutting the S-B_LRE distribution at 3.68 produces good specificity (.90–.92) but variable sensitivity (.06–.38). Passing or failing FMS or S-B_LRE is unrelated to age, gender and IQ.

The data from this study suggest that in a pediatric sample, adjusted cutoffs on the FMS and S-B_LRE ensure good specificity, but with low or variable sensitivity. Thus, they should not be used in isolation to determine the credibility of a response set. At the same time, they can make valuable contributions to pediatric neuropsychology by providing empirically-supported, expedient and cost-effective indicators to enhance performance validity assessment.     

Metamemory, memory performance, and causal attributions in gifted and average children

Fifth and seventh graders who had been teacher-selected as high- or average-achieving were tested on the Kognitiver F?higkeits Test, a standardized test of intellectual abilities for German children. Children who met preestablished criteria as gifted or average were then tested on measures of metacognitive knowledge, attributional beliefs, and performance on a sort recall task. Results indicated ability-related differences in metamemory and sort recall performances. Responses to the attributional questionnaires also varied systematically according to ability: gifted children were more likely to attribute their academic successes to high ability than were average children, who showed a stronger belief in the importance of effort in determining task outcomes. Causal modeling analyses illustrated the strength of metacognitive knowledge as a performance predictor on the memory task, especially for average children. Results are discussed in terms of the value of metacognitive theory in understanding individual performance differences.     

Exogenous influences on task set activation in task switching

To explore the effect of exogenous processes on cognitive control, we used a cueing task-switching paradigm with two spatial judgement tasks and added an irrelevant colour attribute to the task-relevant spatial attribute of the target. The colour was not related to any specific Stimulus–Response relation in the tasks. A correlation was created between stimulus colour and task identity. This correlation was strong but imperfect in Experiment 1 and perfect in Experiment 2. As a result of the colour–task correlation, stimuli contained redundant information about task identity. By changing the correlation pattern every few blocks we caused this information to be sometimes invalid. In both experiments, performance was worse when the information carried by the target was invalid than when it was valid. However, this effect was exclusive to conditions with short task preparation time. By comparing performance with a control group, which had no colour–task correlation (in Experiment 2) we established that the colour manipulation did not cause a qualitative change in preparation strategy, and that the exogenous effect was stronger in switch trials than in repetition trials. We conclude that exogenous processes that are related to task set affect performance primarily if they are presented before endogenous processes of task set preparation have been launched.     

Exogenous influences on task set activation in task switching

To explore the effect of exogenous processes on cognitive control, we used a cueing task-switching paradigm with two spatial judgement tasks and added an irrelevant colour attribute to the task-relevant spatial attribute of the target. The colour was not related to any specific Stimulus-Response relation in the tasks. A correlation was created between stimulus colour and task identity. This correlation was strong but imperfect in Experiment 1 and perfect in Experiment 2. As a result of the colour-task correlation, stimuli contained redundant information about task identity. By changing the correlation pattern every few blocks we caused this information to be sometimes invalid. In both experiments, performance was worse when the information carried by the target was invalid than when it was valid. However, this effect was exclusive to conditions with short task preparation time. By comparing performance with a control group, which had no colour-task correlation (in Experiment 2) we established that the colour manipulation did not cause a qualitative change in preparation strategy, and that the exogenous effect was stronger in switch trials than in repetition trials. We conclude that exogenous processes that are related to task set affect performance primarily if they are presented before endogenous processes of task set preparation have been launched.     

Psychometric properties of the Movement Assessment Battery for Children‐Checklist as a screening instrument for children with a developmental co‐ordination disorder

Background: The Checklist of the Movement Assessment Battery for Children (MABC) was developed to screen children for movement difficulties in the school situation. However, the psychometric properties of the Checklist have not been investigated in detail. Aim: The psychometric properties of the M‐ABC Checklist were investigated including its usefulness as a screening instrument. Samples: A group of 120 children, 6 to 11 years old, randomly selected from mainstream schools and a group of 64 children, 6 to 9 years old, referred for assessment of their motor functioning. Methods: A reliability analysis was performed to investigate whether the 48 items of the Checklist measure the same construct. Construct validity was investigated by means of a factor analysis. And lastly, the sensitivity, specificity and positive predictive value of the Checklist were investigated by comparing the performance of children on both the Test and Checklist of the M‐ABC. Results: The items of the Checklist measure the same construct. Seven factors were obtained after factor analysis, revealing that the Checklist measures a broad range of motor skills. The Checklist met the standards for sensitivity in all age groups, except in the 8‐year‐old group, where too many children with motor problems were not detected. With the exception of the 6‐year‐old children, specificity was poor. The positive predictive value was acceptable, except for the 7‐year‐old children. Conclusion: the Checklist proved to meet standards for reliability and most aspects of validity. Its use by teachers for screening children with movement difficulties can be recommended.     

RBANS Validity Indices: a Systematic Review and Meta-Analysis

Neuropsychology practice organizations have highlighted the need for thorough evaluation of performance validity as part of the neuropsychological assessment process. Embedded validity indices are derived from existing measures and expand the scope of validity assessment. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) is a brief instrument that quickly allows a clinician to assess a variety of cognitive domains. The RBANS also contains multiple embedded validity indicators. The purpose of this study was to synthesize the utility of those indicators to assess performance validity. A systematic search was completed, resulting in 11 studies for synthesis and 10 for meta-analysis. Data were synthesized on four indices and three subtests across samples of civilians, service members, and veterans. Sufficient data for meta-analysis were only available for the Effort Index, and related analyses indicated optimal cutoff scores of ≥1 (AUC?=?.86) and?≥?3 (AUC?=?.85). However, outliers and heterogeneity were present indicating the importance of age and evaluation context. Overall, embedded validity indicators have shown adequate diagnostic accuracy across a variety of populations. Recommendations for interpreting these measures and future studies are provided.     

Sequencing strategies in children 18–24 months: Limitations imposed by task complexity

Researchers have generally reported that very young children lack the orderly, sequential approach to tasks that characterizes skilled action. This study questions that assumption by investigating to what extent deficits in sequencing are a function of task complexity (type and number of elements), and to what extent sequencing ability is tied to competent task performance. Three tasks—the Lock Box, Pegboards, and Object Grouping—were each presented in two forms, varying only in number of elements. Participants were 38 children between 18 and 24 months of age. The Denver Developmental Screening Test was also administered to all children. When number of task elements increased, there was a dramatic decrease in orderliness of approach. Type of task served to exaggerate or minimize these effects. However, irrespective of task complexity, children used a consistent pattern of organization, generally two or three sequential movements. This strategy, though serving well for tasks of limited dimensions, was inadequate for tasks with more than four or five elements. Sequencing skills, as well as other aspects of performance, were significantly correlated with Denver scores. Results suggest that exceeding the limits of young children's organizing abilities may obscure actual capacities. The role of task complexity in the performance of young children is discussed as it relates to developmental processes, clinical assessment, and teaching.     

Prospective Memory and Pediatric Traumatic Brain Injury: Effects of Cognitive Demand

This study investigated the effects of pediatric traumatic brain injury (TBI) on prospective memory. Fourteen children and 14 adolescents with TBI were compared with 25 and 23 noninjured children and adolescents, respectively. Based on a prefrontal model, the cognitive demand on the ongoing component of a prospective-memory task was manipulated. Overall, those with TBI had poorer prospective-memory performance than their noninjured peers. Performance was worse in a high cognitive-demand condition than a low, and younger children performed worse than adolescents. Decreases in performance from the low- to high-demand conditions were not significantly different between the two children's groups but were between the two adolescents' groups. Furthermore, the age and injury effects were reflected in the performances on executive function tests: the Self-ordered Pointing Task (SOPT), and the Stroop Color Word Interference Test. The Tower of London (TOL), which did not produce age or injury effects, was nevertheless found to be an important predictor of performance on the high-demand task in those with TBI. Although previous research has demonstrated impaired prospective memory performance in children with TBI, this study attempted to explain why this might occur, specifically that the prefrontal regions might be implicated.     

Prospective memory and pediatric traumatic brain injury: effects of cognitive demand.

This study investigated the effects of pediatric traumatic brain injury (TBI) on prospective memory. Fourteen children and 14 adolescents with TBI were compared with 25 and 23 noninjured children and adolescents, respectively. Based on a prefrontal model, the cognitive demand on the ongoing component of a prospective-memory task was manipulated. Overall, those with TBI had poorer prospective-memory performance than their noninjured peers. Performance was worse in a high cognitive-demand condition than a low, and younger children performed worse than adolescents. Decreases in performance from the low- to high-demand conditions were not significantly different between the two children's groups but were between the two adolescents' groups. Furthermore, the age and injury effects were reflected in the performances on executive function tests: the Self-ordered Pointing Task (SOPT), and the Stroop Color Word Interference Test. The Tower of London (TOL), which did not produce age or injury effects, was nevertheless found to be an important predictor of performance on the high-demand task in those with TBI. Although previous research has demonstrated impaired prospective memory performance in children with TBI, this study attempted to explain why this might occur, specifically that the prefrontal regions might be implicated.     

Virtual-reality-based attention assessment of ADHD: ClinicaVR: Classroom-CPT versus a traditional continuous performance test

Virtual-reality-based assessment may be a good alternative to classical or computerized neuropsychological assessment due to increased ecological validity. ClinicaVR: Classroom-CPT (VC) is a neuropsychological test embedded in virtual reality that is designed to assess attention deficits in children with attention deficit hyperactivity disorder (ADHD) or other conditions associated with impaired attention. The present study aimed to (1) investigate the diagnostic validity of VC in comparison to a traditional continuous performance test (CPT), (2) explore the task difficulty of VC, (3) address the effect of distractors on the performance of ADHD participants and typically-developing (TD) controls, and (4) compare the two measures on cognitive absorption. A total of 33 children diagnosed with ADHD and 42 TD children, aged between 7 and 13 years, participated in the study and were tested with a traditional CPT or with VC, along with several cognitive measures and an adapted version of the Cognitive Absorption Scale. A mixed multivariate analysis of covariance (MANCOVA) revealed that the children with ADHD performed worse on correct responses had more commissions and omissions errors than the TD children, as well as slower target reaction times . The results showed significant differences between performance in the virtual environment and the traditional computerized one, with longer reaction times in virtual reality. The data analysis highlighted the negative influence of auditory distractors on attention performance in the case of the children with ADHD, but not for the TD children. Finally, the two measures did not differ on the cognitive absorption perceived by the children.     

Children's internal representations,empathy, and fantasy play: a validity study of the SCORS-Q

The authors investigated relationships among internal representations, empathy, and affective and cognitive processes in fantasy play to test the validity of the Social Cognition and Object Relations Scale Q-Sort (SCORS-Q; D. Westen, 1995) with children. Eighty-six 8-10-year-olds were administered 8 Thematic Apperception Test cards, a standardized play task, and a self-report empathy measure. Teachers rated children's empathy and helpfulness. As predicted, internal representations were related to empathy, helpfulness, and quality of fantasy play. Developmental differences on the SCORS-Q were consistent with object relations theory and with results from the original SCORS. The findings support the value of internal representations as a means of understanding children's interpersonal functioning and contribute to the validity of the SCORS-Q for use with children.     

Cognitive estimations as a measure of executive dysfunction in childhood epilepsy

Children and adolescents with epilepsy are known to demonstrate executive function deficits. Despite prior work that has shown that cognitive estimation tasks are sensitive to executive dysfunction in children, such tasks have not been studied in children with epilepsy. This is particularly important given the fact that executive tasks have heretofore shown poor ecological validity, and it has been speculated that estimation tasks may show stronger ecological validity than other executive tests. One hundred and thirteen clinically referred children and adolescents with epilepsy were included. The Biber Cognitive Estimations Test was sensitive to cognitive dysfunction, with about half showing impairments on this task in comparison to age-matched normative data; the most frequently impaired subscales were quantity estimation and time estimation. Moreover, the Biber Cognitive Estimation Test showed moderate correlations with not only overall intellectual functions and academic achievement but also other commonly administered tests of executive functions, including digit span, Trailmaking, and the Tower of London but not with the contingency naming test. Cognitive estimations were also modestly correlated with age of epilepsy onset but not other epilepsy-severity variables such as number of antiepilepsy drugs (AEDs) or seizure frequency. Unfortunately, the hypothesis that the Biber Cognitive Estimation Test would show strong ecological validity was not supported, as it showed weak relations with parent-reported executive function deficits. The significance and limitations of this investigation are discussed.     

Validity rates of the Personality Assessment Inventory and the Minnesota Multiphasic Personality Inventory-2 in a VA Medical Center Setting

In this study, we compared protocol validity rates between the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and the Personality Assessment Inventory (PAI; Morey, 1991) in a veteran population. Veterans (N=472) were administered both instruments as part of routine psychological evaluations. Profile validity was based on previously published criteria. When applying primary validity indicators, inpatients produced significantly fewer invalid PAI profiles (37%) than MMPI-2 profiles (63%). We found similar results among outpatients for which we considered 47% of MMPI-2 profiles invalid compared to only 21% of PAI profiles. When applying both primary and supplementary validity indicators, both inpatients and outpatients continued to produce fewer invalid PAI profiles than MMPI-2 profiles. We discuss factors that may be related to the differences in validity rates.     

A Cross‐Cultural Study of Task Specificity in Creativity

This study provides new evidence concerning task specificity in creativity—examining through a cross‐cultural perspective the extent to which performance in graphic versus verbal creativity tasks (domain specificity) and in divergent versus convergent creativity tasks (process specificity) are correlated. The relations between different creativity tasks in monocultural and multicultural samples of Chinese and French children were compared. Electronic versions of the Wallach and Kogan Creativity Test (WKCT , W allach & K ogan, 1965; L au & C heung, 2010) and the Evaluation of Potential Creativity (EP oC; L ubart, B esançon, & B arbot, 2011; B arbot, B esançon, & L ubart, 2011) were used. Both measures showed satisfactory psychometric properties and cross‐cultural structural validity. The results showed that culture has an impact on the structure of creative ability: It appeared that correlation patterns were different across Chinese and French groups and across monocultural and multicultural groups. Such results show that it is crucial to take task specificity into account when investigating the effect of culture on creativity. Indeed, our study implies that cultural differences that are found using one specific creativity task might not be automatically generalizable to all sorts of creativity tasks. Limitations are discussed and perspectives for future research on culture and task specificity in creativity are proposed.     

Attention performance in an epidemiological sample of urban children: The role of gender and verbal intelligence

Abstract

We administered a comprehensive attentional battery to an epidemiologically defined sample of 435 first-and second-grade children to assess the influence of gender and verbal intelligence on attention. The battery included three versions of the continuous performance test (CPT), two digit cancellation tasks, three subtests from the WISC-R, and the Wisconsin Card Sorting Test. The results indicated that both gender and intelligence had an impact on attentional performance. Girls performed better than boys; they made fewer errors on the CPT and obtained higher scores on the digit cancellation task and the Coding subtest of the WISC-R. Children with higher verbal intelligence also performed better on the attentional tests, but this advantage was not observed across measures or levels of performance. For example, children with limited verbal skills performed significantly worse than their peers only in measures with high processing demands (the degraded CPT and the distraction version of the digit cancellation task).     

An evaluation of the yellow brick road test through a full prediction-performance comparison matrix

The purpose of the present study was to evaluate the predictive validity of the Yellow Brick Road Test (YBRT) relative to performance in reading as measured by the Metropolitan Achievement Test (MAT). A full prediction-performance comparison matrix was employed to compare three different cutoff scores for the YBRT for the identification of “at-risk” children. Four hundred and fourteen kindergarten-aged children were administered the YBRT, 214 of whom were followed to the end of second grade. It was concluded that the YBRT is a moderately valid instrument for predicting the level of reading achievement in a population with a different average performance level from the normative sample. However, the results of this study failed to support the utility of the test author's suggested use of a score of 120 as the cutoff score. Finally, it is recommended that a prediction-performance comparison study be considered standard methodology for the evaluation of the validity and efficiency of screening instruments.     

The Effect of Challenge and Threat Appraisals Under Evaluative Presence

Four studies were conducted to examine whether cognitive appraisals, manipulated through task instructions, would moderate social‐facilitation effects. In Study 1, participants in the challenge condition performed better on a mental arithmetic task when the experimenter was present. Conversely, participants in the threat condition performed worse when the experimenter was present. Study 2 extended these findings across 2 math tasks that varied in degree of difficulty. The pattern of performance data failed to support prior drive theories and provided support for a unique contribution of cognitive appraisals in explaining social‐facilitation effects. Study 3 validated the appraisal manipulations by using multiple measures of cognitive appraisals. Finally, Study 4 offered increased validity by replicating the performance data using an anagram task.     

Assessing individual differences in achievement motivation with the Implicit Association Test

The authors examined the validity of an Implicit Association Test (Greenwald, McGhee, & Schwartz, 1998) for assessing individual differences in achievement tendencies. Eighty-eight students completed an IAT and explicit self-ratings of achievement orientation, and were then administered a mental concentration test that they performed either in the presence or in the absence of achievement-related feedback. Implicit and explicit measures of achievement orientation were uncorrelated. Under feedback, the IAT uniquely predicted students’ test performance but failed to predict their self-reported task enjoyment. Conversely, explicit self-ratings were unrelated to test performance but uniquely related to subjective accounts of task enjoyment. Without feedback, individual differences in both performance and enjoyment were independent of differences in either of the two achievement orientation measures.     

Inhibitory processes, working memory, phonological awareness, naming speed, and early arithmetic achievement

This study identified the cognitive processes that underlie the individual differences in early mathematical performance in elementary school children. Taking into account the Baddeley framework multicomponent model, the inhibitory processes, working memory, phonological awareness, and naming speed are considered to be related to early math learning. To examine this relationship, we compared the performance of a total of 424 typically developing middle-class children, aged between 4 and 7 years in a battery of cognitive and early numeric tests: The Utrecht Early Numeracy Test, the Rapid Automatized Naming Test, Spanish version of the Stroop task, the Numeracy Interference Test, Digit Span test, and Phonological Knowledge Test. The mean age of the participants was 72.21 months (sd = 14.8), and 48.6% were male and 51.4% were female. The results demonstrated that children performing worst on central executive, phonological processing, and inhibitory processes showed lower results in early mathematical tasks measured by The Utrecht Early Numeracy Test. Results supported the notion that the executive system is an important predictor of children's mathematical performance.