Official Position of the American Academy of Clinical Neuropsychology Social Security Administration Policy on Validity Testing: Guidance and Recommendations for Change.

UNLABELLED: The milestone publication by Slick, Sherman, and Iverson (1999) of criteria for determining malingered neurocognitive dysfunction led to extensive research on validity testing. Position statements by the National Academy of Neuropsychology and the American Academy of Clinical Neuropsychology (AACN) recommended routine validity testing in neuropsychological evaluations. Despite this widespread scientific and professional support, the Social Security Administration (SSA) continued to discourage validity testing, a stance that led to a congressional initiative for SSA to reevaluate their position. In response, SSA commissioned the Institute of Medicine (IOM) to evaluate the science concerning the validation of psychological testing. The IOM concluded that validity assessment was necessary in psychological and neuropsychological examinations (IOM, 2015 ). OBJECTIVE: The AACN sought to provide independent expert guidance and recommendations concerning the use of validity testing in disability determinations. METHOD: A panel of contributors to the science of validity testing and its application to the disability process was charged with describing why the disability process for SSA needs improvement, and indicating the necessity for validity testing in disability exams. RESULTS: This work showed how the determination of malingering is a probability proposition, described how different types of validity tests are appropriate, provided evidence concerning non-credible findings in children and low-functioning individuals, and discussed the appropriate evaluation of pain disorders typically seen outside of mental consultations. CONCLUSIONS: A scientific plan for validity assessment that additionally protects test security is needed in disability determinations and in research on classification accuracy of disability decisions.

Monoclonal paraproteinemia with subacute encephalopathy, seizures, and scleromyxedema.

For 3 months, a 37-year-old man developed memory loss and personality changes, followed by fever, seizures, bilateral upper motor neuron signs, and increased CSF protein with skin induration that was compatible with scleromyxedema. An IgG-type paraproteinemia was identified. He improved with plasmapheresis, but died in acute respiratory and renal failure. Autopsy revealed right temporal demyelination and meningeal inflammation.

Differential drawing size associated with unilateral brain damage.

Size of Greek Cross reproductions was compared using 35 persons having unilateral right (RHD), 35 having unilateral left (LHD) hemisphere damage and 38 non-neurologic controls. With right hand tapping speed statistically controlled, RHD drawings were significantly larger than LHD reproductions. Spatial Relations scores were significantly associated with drawing size in the RHD group only, following adjustment for right hand tapping speed. Aphasia Screening scores were unrelated to drawing size. These data demonstrate that LHD/RHD drawing size differences are independent of any basic motor impairment and that for RHD subjects, drawing size is positively correlated with visuospatial impairment.

Visual agnosia contrasted with visual-verbal disconnection.

Serial neuropsychological findings are contrasted in two cases: one with a syndrome of visual agnosia, the other with a disorder resulting from visual-verbal disconnection. Both patients were impaired in confrontation naming of objects and pictures, but the patient with visual-verbal disconnection was able to perform tasks of color-object matching and pantomime recognition, whereas the patient with visual agnosia could not do so, demonstrating a failure to establish meaningful nonverbal visual-visual association. Additionally, the performance of the patient with visual agnosia reflected an evolution from the apperceptive to associative forms of the disorder, suggesting that the various impairments of visual identification form a continuum of related disorders.

Factors attenuating the validity of the Geriatric Depression Scale in a dementia population.

OBJECTIVE: The validity of the Geriatric Depression Scale (GDS) in cognitively impaired patients has been questioned. We investigated possible factors (memory loss, dementia severity, unawareness of illness) attenuating the validity of the GDS in patients with dementia. PATIENTS: Eighty-three patients who met research diagnostic criteria for "probable Alzheimer's disease." Subjects with major depressive disorder were excluded. Dementia severity ranged from mild to moderate. SETTING: Outpatient clinics, including institutional settings and private research settings. MEASUREMENTS: Depression--GDS; Hamilton Depression Scale. Memory--Wechsler Memory Scale; Benton Visual Retention Test. Dementia severity--Mini-Mental State Examination. Self-awareness of cognitive deficits--Difference score between a self-report memory questionnaire and an informant-rated memory questionnaire. RESULTS: Multiple regression analysis revealed that Hamilton scores were the major predictor of GDS scores. Memory scores and self-awareness scores were also significant predictors. Dementia severity scores were not a significant predictor. CONCLUSIONS: The GDS is a valid measure of mild-to-moderate depressive symptoms in Alzheimer patients with mild-to-moderate dementia. However, Alzheimer patients who disavow cognitive deficits also tend to disavow depressive symptoms, and the GDS should be used with caution in such patients. Finally, the argument that memory impairment precludes accurate self-report of recent mood is negated by our finding that many patients accurately reported depressive symptoms and that worse memory was associated with more self-reported depressive symptoms.

Diagnosis, assessment and treatment of age-associated memory impairment.

We have reviewed diagnostic criteria and assessment procedures for AAMI, as well as pharmacologic and behavioral treatments for this condition. This research gives reason to hope that an important behavioral deficit associated with aging may be modified through drug and behavioral treatment.

Memory self-report in Alzheimer's disease and in age-associated memory impairment.

We investigated memory self-report in Alzheimer's disease (AD) and age-associated memory impairment (AAMI). AD and AAMI patients and healthy elderly subjects were administered a self-report memory questionnaire, memory tests, a family-rated memory questionnaire, and a depression scale. The AD group reported worse memory than the control group, but many individual AD subjects reported normal memory. This finding confirms clinical observations that unawareness of memory loss is common in AD but variable across patients. Multiple regression analysis revealed that worse memory self-ratings were associated with greater dementia severity and higher depression scores. In the AAMI group, memory self-ratings were predicted by family ratings of memory ability but not by memory test scores. There was a nonsignificant trend for depression scores to predict memory self-ratings. Finally, level of self-reported memory ability did not differ for AD and AAMI, contradicting clinical lore that memory complaint is a useful diagnostic indicator.

Diagnosis and assessment of age-associated memory impairment.

Age-associated memory impairment (AAMI) is a diagnostic term applied to healthy persons greater than 50 years of age who have experienced a gradual decline in memory that lies within the boundaries of normality. Although the behavioral deficits associated with AAMI are modest in comparison to those associated with dementing disorders such as Alzheimer's disease, they are quite troublesome to many middle-aged and elderly adults engaged in intellectually demanding activities. In this article, diagnostic criteria for AAMI will be provided, new psychometric instruments for assessing the behavioral deficits seen in AAMI will be described, and results of large multinational studies with these instruments will be presented. Finally, behavioral and pharmacologic strategies for treating AAMI will be discussed.

Do men show more rapid age-associated decline in simulated everyday verbal memory than do women?

Recent magnetic resonance imaging data suggest that men show more rapid age-associated atrophy of the left hemisphere than do women. To investigate whether a similar pattern occurs for functional decline, the authors tested 417 male-female pairs, ages 17-79 years and matched perfectly on age and education, on 3 computer-simulated everyday verbal memory tests: Name-Face Association, First-Last Name Associate Learning, and Grocery List Selective Reminding. Age and gender significantly predicted performance on all 3 tests. By contrast, only 1 of 15 Age x Gender interactions was significant, accounting for merely 1% of the test variance. These data suggest that although gender-based differences in rate of left-hemisphere structural decline may occur with normal aging, these apparently do not translate into differential functional decline in simulated everyday verbal memory.

A self-rating scale for evaluating memory in everyday life.

A memory self-rating scale is described that includes 21 ability-to-remember items, 24 items assessing frequency of occurrence of memory failures, and 4 global rating items assessing overall comparison to others, comparison to the best one's memory has ever been, speed of recall, and concern or worry over memory function. Factor analysis yielded 5 orthogonal Ability to Remember and 5 orthogonal Frequency of Occurrence factors. The factor structure was not affected by age or sex, and level of complaint on the factor scores was not strongly associated with age.

Structure of everyday memory in adults with Age-Associated Memory Impairment.

Everyday memory was tested in a group of adults manifesting Age-Associated Memory Impairment; a computerized battery of tests was constructed to simulate memory tasks of daily life. Confirmatory and other structural equation models were estimated for the entire sample of 273 Ss and for 3 age groups. A 4-factor model was found to fit the data well and was invariant across age and gender. After education had been controlled, only the General Recall factor was found to be consistently related to age in both men and women; the other 3 factors--Narrative Memory, Digit Recall, and Visual Memory--were related to age only in men. Confirmatory factor analyses of the everyday memory tests combined with several psychometric memory tests suggested that some of the latter (the Benton Visual Retention Test and Wechsler Memory Scale Hard Paired Associates) load on more than 1 factor of everyday memory, suggesting complex relationships between the 2 types of tests.

Normative data on a self-rating scale for evaluating memory in everyday life.

Normative data are provided on 1,106 subjects who were administered a memory self-rating scale. This scale includes 21 ability-to-remember items yielding 5 factors, 24 items assessing frequency-of-occurrence of memory failures yielding five factors, and four global rating items assessing overall comparison to others, comparison to the best one's memory has been, speed of recall, and concern or worry over memory function. Test-retest reliabilities of the various self-rating factors exceeded .80. Research and clinical applications are discussed.

Construct validity of the Continuous Visual Memory Test.

The construct validity of the Continuous Visual Memory Test (CVMT), a new measure of visual recognition memory was evaluated based on the performance of 92 healthy, normal adults. A series of factor analyses were conducted utilizing marker variables for verbal memory, visual memory, attention and concentration, and verbal and visual/nonverbal intellectual functions. CVMT acquisition scores were associated with verbal and visual/nonverbal intellectual factors as well as with attentional ability. The CVMT delayed recognition score was shown to be a factorially "pure" measure of visual memory.

First-Last Names and the Grocery List Selective Reminding Test: two computerized measures of everyday verbal learning.

Data are presented on two computerized tests of everyday verbal learning: Paired associate learning of First-Last Names (FLN), and the Grocery List Selective Reminding Test (GLSRT). MANOVA and multiple regression analyses demonstrated that performance on FLN and GLSRT was most strongly related to age, with significant secondary associations found for gender, with females performing better than males. Additional factor analysis of FLN and GLSRT supported the construct validity of these measures by demonstrating significant associations of performance with traditional newopsychological measures of memory and related functions, including the Paired Associate Learning and Logical Memory subtests from the Wechsler Memory Scale, the Benton Visual Retention Test, and WAIS Digit Symbol.

Multiple equivalent test forms in a computerized, everyday memory battery.

Eight parallel forms for six computerized, everyday memory tests were examined for equivalence of difficulty level. Six equivalent forms were found for Telephone Dialing, Name-Face Association, First-Last Name memory, and Grocery List Learning, white eight equivalent forms were found for Misplaced Objects and Recognition of Faces. The clinical and research utility of multiple equivalent forms of everyday memory tests is discussed.

Traditional and computerized assessment procedures applied to the evaluation of memory change after temporal lobectomy.

After establishing that 40 temporal lobectomy patients (20 right, 20 left) demonstrated the same pattern of memory compromise as has been reported in prior studies, we examined the sensitivity of computerized tests of everyday memory skills to the cognitive change associated with temporal resection. Multiple cognitive deficits occur after left, but not after right, temporal lobectomies. Memory impairment after surgery is not limited to traditionally structured memory tests but is also evident on tasks designed to simulate activities of daily life.

Association between IQ and neuropsychological test performance: commentary on Tremont, Hoffman, Scott, and Adams (1998).

Recently, Tremont, Hoffman, Scott, and Adams (1998) demonstrated an association between Halstead-Reitan (HRB) and Wechsler Memory Scale (WMS) performance and WAIS-R IQ scores, and recommended that premorbid intellectual estimates be utilized as general indicators of expected neuropsychological test performance. The commentary presented here demonstrates that the relationship between IQ, HRB and WMS is due to shared common factors, and argues against the use of premorbid IQ estimates, because of significant regression to the mean. "Intelligence" is redefined as the composite of neurobehavioral abilities covered in comprehensive neuropsychological assessment.

Another look at VIQ-PIQ scores and unilateral brain damage.

The relationship of WAIS, VIQ, PIQ and Aphasia Screening scores to unilateral brain damage was investigated using 18 subjects with left hemisphere damage (LHD) and 19 subjects with right hemisphere damage (RHD). Expected VIQ-PIQ difference scores were demonstrated only for the RHD subjects. Aphasia was significantly associated with PIQ in the LHD group. ANCOVAR using Aphasia Screening as a covariate produced significant LHD versus RHD differences on PIQ. These data question the utility of VIQ-PIQ difference scores in the diagnosis of unilateral brain damage. Second, the data suggest that LHD "non-verbal" deficits are the result of underlying language disturbance and not the consequence of impaired visuoperceptive or visuospatial processes.