The Impact of Adverse Childhood Experiences on Symptom and Performance Validity Tests Among a Multiracial Sample Presenting for ADHD Evaluation.

OBJECTIVE: Adverse childhood experiences (ACEs) are commonly reported in individuals presenting for attention-deficit hyperactivity disorder (ADHD) evaluation. Performance validity tests (PVTs) and symptom validity tests (SVTs) are essential to ADHD evaluations in young adults, but extant research suggests that those who report ACEs may be inaccurately classified as invalid on these measures. The current study aimed to assess the degree to which ACE exposure differentiated PVT and SVT performance and ADHD symptom reporting in a multi-racial sample of adults presenting for ADHD evaluation. METHOD: This study included 170 adults referred for outpatient neuropsychological ADHD evaluation who completed the ACE Checklist and a neurocognitive battery that included multiple PVTs and SVTs. Analysis of variance was used to examine differences in PVT and SVT performance among those with high (≥4) and low (≤3) reported ACEs. RESULTS: Main effects of the ACE group were observed, such that high ACE group reporting demonstrated higher scores on SVTs assessing ADHD symptom over-reporting and infrequent psychiatric and somatic symptoms on the Minnesota Multiphasic Personality Inventory-2-Restructured Form. Conversely, no significant differences emerged in total PVT failures across ACE groups. CONCLUSIONS: Those with high ACE exposure were more likely to have higher scores on SVTs assessing over-reporting and infrequent responses. In contrast, ACE exposure did not affect PVT performance. Thus, ACE exposure should be considered specifically when evaluating SVT performance in the context of ADHD evaluations, and more work is needed to understand factors that contribute to different patterns of symptom reporting as a function of ACE exposure.

Comparing embedded performance validity indicators within the WAIS-IV Letter-Number sequencing subtest to Reliable Digit Span among adults referred for evaluation of attention-deficit/hyperactivity disorder.

Objectives: This study investigated the Wechsler Adult Intelligence Scale-Fourth Edition Letter-Number Sequencing (LNS) subtest as an embedded performance validity indicator among adults undergoing an attention-deficit/hyperactivity disorder (ADHD) evaluation, and its potential incremental value over Reliable Digit Span (RDS). Method: This cross-sectional study comprised 543 adults who underwent neuropsychological evaluation for ADHD. Patients were divided into valid (n = 480) and invalid (n = 63) groups based on multiple criterion performance validity tests. Results: LNS total raw scores, age-corrected scaled scores, and age- and education-corrected T-scores demonstrated excellent classification accuracy (area under the curve of .84, .83, and .82, respectively). The optimal cutoff for LNS raw score (≤16), age-corrected scaled score (≤7), and age- and education-corrected T-score (≤36) yielded .51 sensitivity and .94 specificity. Slightly lower sensitivity (.40) and higher specificity (.98) was associated with a more conservative T-score cutoff of ≤33. Multivariate models incorporating both LNS and RDS improved classification accuracy (area under the curve of .86), and LNS scores explained a significant but modest proportion of variance in validity status above and beyond RDS. Chaining LNS T-score of ≤33 with RDS cutoff of ≤7 increased sensitivity to .69 while maintaining ≥.90 specificity. Conclusions: Findings provide preliminary evidence for the criterion and construct validity of LNS as an embedded validity indicator in ADHD evaluations. Practitioners are encouraged to use LNS T-score cutoff of ≤33 or ≤36 to assess the validity of obtained test data. Employing either of these LNS cutoffs with RDS may enhance the detection of invalid performance.

Differentiating Performance on the Connors Continuous Performance Test (CPT-3) as a Function of Comorbid Internalizing Psychopathology.

OBJECTIVE: Internalizing psychopathology commonly co-occurs with attention-deficit/hyperactivity disorder (ADHD). Attention concerns are present in both ADHD and internalizing disorders, yet the neuropsychological functioning of those with comorbid ADHD and internalizing psychopathology is underexamined. METHOD: This study compared Conners' Continuous Performance Test-Third Edition (CPT-3) profiles across ADHD (n = 141), internalizing psychopathology (n = 78), and comorbid (ADHD/internalizing psychopathology; n = 240) groups. RESULTS: Compared to the internalizing psychopathology group, the comorbid group had higher mean T-scores on CPT-3 indices indicative of inattentiveness and impulsivity and more clinically elevated T-scores (T>60) on indices measuring inattentiveness and impaired sustained attention. Patients in the comorbid group were also more likely to have abnormal overall CPT-3 profiles (>2 elevated T-scores) than the ADHD and psychopathology only groups. CONCLUSION: Patients with comorbid ADHD/internalizing psychopathology may evidence a more impaired attentional performance on the CPT-3, which could aid in more tailored treatment planning.

Cross-validating the Clinical Assessment of Attention Deficit-Adult symptom validity scales for assessment of attention deficit/hyperactivity disorder in adults.

INTRODUCTION: The Clinical Assessment of Attention Deficit-Adult is among the few questionnaires that offer validity indicators (i.e., Negative Impression [NI], Infrequency [IF], and Positive Impression [PI]) for classifying underreporting and overreporting of attention-deficit/hyperactivity disorder (ADHD) symptoms. This is the first study to cross-validate the NI, IF, and PI scales in a sample of adults with suspected or known ADHD. METHOD: Univariate and multivariate analyses were conducted to examine the independent and combined value of the NI, IF, and PI scores in predicting invalid symptom reporting and neurocognitive performance in a sample of 543 adults undergoing ADHD evaluation. RESULTS: The NI scale demonstrated better classification accuracy than the IF scale in discriminating patients with and without valid scores on measures of overreporting. Only NI scores significantly predicted validity status when used in combination with IF scores. Optimal cut-scores for the NI (≤51; 30% sensitivity / 90% specificity) and IF (≥4; 18% sensitivity / 90% specificity) scales were consistent with those reported in the original manual; however, these indicators poorly discriminated patients with invalid and valid neurocognitive performance. The PI scale demonstrated acceptable classification accuracy in discriminating patients with invalid and valid scores on measures of underreporting, albeit with an optimal cut-score (≥27; 36% sensitivity / 90% specificity) lower than that described in the manual. CONCLUSION: Findings provide preliminary evidence of construct validity for these scales as embedded validity indicators of symptom overreporting and underreporting. However, these scales should not be used to guide clinical judgment regarding the validity of neurocognitive test performance.

Multivariate examination of embedded indicators of performance validity for ADHD evaluations: A targeted approach.

This study investigated the individual and combined utility of 10 embedded validity indicators (EVIs) within executive functioning, attention/working memory, and processing speed measures in 585 adults referred for an attention-deficit/hyperactivity disorder (ADHD) evaluation. Participants were categorized into invalid and valid performance groups as determined by scores from empirical performance validity indicators. Analyses revealed that all of the EVIs could meaningfully discriminate invalid from valid performers (AUCs = .69-.78), with high specificity (≥90%) but low sensitivity (19%-51%). However, none of them explained more than 20% of the variance in validity status. Combining any of these 10 EVIs into a multivariate model significantly improved classification accuracy, explaining up to 36% of the variance in validity status. Integrating six EVIs from the Stroop Color and Word Test, Trail Making Test, Verbal Fluency Test, and Wechsler Adult Intelligence Scale-Fourth Edition was as efficacious (AUC = .86) as using all 10 EVIs together. Failing any two of these six EVIs or any three of the 10 EVIs yielded clinically acceptable specificity (≥90%) with moderate sensitivity (60%). Findings support the use of multivariate models to improve the identification of performance invalidity in ADHD evaluations, but chaining multiple EVIs may only be helpful to an extent.

Associations Between Social Context and Mood During Alcohol Consumption in Young Adult Smokers.

OBJECTIVE: Differences in the subjective effects of alcohol in different social contexts have been well documented, but little research examines affect during drinking in real-world social contexts. This study examined differences by social context in negative affect and positive affect during alcohol consumption. We hypothesized that negative affect and positive affect with drinking would vary as a function of social context (alone or with others). METHOD: A total of 257 young adults (M age = 21.3, 53.3% female) who were enrolled in a longitudinal, observational study assessing risk for smoking completed 7 days of ecological momentary assessment assessing alcohol use, affect, and social context at two time points of the study. Mixed-effects location scale analyses examined effects of being alone versus with others on positive affect and negative affect after drinking and compared with nondrinking times. RESULTS: Positive affect was higher when drinking with others versus alone, and negative affect was higher when drinking alone versus with others. Both negative affect and positive affect variability were higher when participants were drinking alone compared to with others, and negative affect variability was higher at low amounts of alcohol but decreased with increased drinking. CONCLUSIONS: These findings demonstrate that solitary drinking is less consistently reinforcing because of greater and more variable negative affect, as well as more variable positive affect. When drinking with others, increased and less variable positive affect suggests that social drinking may be particularly reinforcing in young adulthood.

Preliminary evidence that individuals with remitted alcohol use disorder and major depressive disorder exhibit enhanced neural responses to reward: An EEG study.

INTRODUCTION: Disruptions in neural responses to reward are implicated in risk for Alcohol Use Disorder (AUD) and Major Depressive Disorder (MDD). It is not clear whether these findings extend to those in remission from AUD and MDD, a critical question as studies of remission can (a) rule out effects due to current symptoms, and (b) can reveal potential trait-like differences. METHODS: Individuals with and without remitted AUD (rAUD) and/or rMDD (rMDD) were drawn from a larger study to create four groups: rAUD (n = 54), rMDD (n = 66), rAUD + rMDD (n = 53), and a community control group (CCG; n = 81). Participants completed a validated monetary reward task during electroencephalogram (EEG). Multilevel models examined group differences in event-related potentials and time-frequency indices of reward and loss responsiveness, namely, reward positivity (RewP), feedback negativity (FN), reward-related delta power, and loss-related theta power. RESULTS: Analyses revealed that the rAUD + rMDD group had significantly higher reward-related delta activity than the three other groups (p-values < 0.01), which did not differ from each other. Sensitivity analyses revealed this relationship fell just above the threshold set for significance after controlling for residual current MDD and AUD symptoms (p =.05). There were no other group differences or significant interactions (p-values > 0.05). CONCLUSIONS: To our knowledge, this is the first study to show that individuals with remitted AUD and MDD demonstrate increased sensitivity to rewards compared to individuals with remitted AUD alone, MDD alone, and without AUD or MDD. These findings suggest heightened motivational salience to reward might be an important factor in comorbid AUD and MDD.

Negative Affect and Cigarette Cessation in Dual Users of Cigarettes and Electronic Nicotine Delivery Systems.

Objectives: Dual use of cigarettes and electronic nicotine delivery systems (ENDS) is increasingly common in adult smokers, who often report using ENDS to quit smoking. Elevated negative affect is an established predictor of increased difficulty quitting smoking combustible cigarettes but has not yet been examined in the context of cigarette cessation for dual users. Method: This study examined whether mood-related factors predict cigarette smoking cessation among dual users (N = 364) over 12-months. Self-reported cigarette smoking at 12 months, with abstinence defined as no smoking for the past 7 days, was the primary outcome variable. Logistic regression included baseline levels of depression symptoms (CES-D), anxiety symptoms (MASQ), and negative affect expectancies for smoking, with baseline nicotine dependence for cigarettes (NDSS), motivation to quit, age, race/ethnicity, rate of cigarette smoking at baseline, and ENDS usage at baseline and 12 months as covariates. Interactions between CES-D, MASQ, and negative affect expectancies were examined. We predicted that negative affect, especially for smokers who had high negative affect expectancies for smoking, would be negatively associated with quitting. Results: Contrary to expectations, negative affect constructs did not predict quitting. Baseline nicotine dependence for cigarettes, gender, and race/ethnicity significantly predicted the likelihood of cigarette cessation. Higher rates of ENDS use, higher motivation, and lower negative affect smoking expectancies were significantly correlated with quitting cigarettes. Conclusion: In this non-treatment seeking sample of dual users, negative affect did not predict cigarette cessation over and above nicotine dependence for cigarettes, gender, and race/ethnicity.

Rapid response is predictive of treatment outcomes in a transdiagnostic intensive outpatient eating disorder sample: a replication of prior research in a real-world setting.

OBJECTIVE: There is a growing call to identify specific outcome predictors in real-world eating disorder (ED) treatment settings. Studies have implicated several ED treatment outcome predictors [rapid response (RR), weight suppression, illness duration, ED diagnosis, and psychiatric comorbidity] in inpatient settings or randomized controlled trials of individual outpatient therapy. However, research has not yet examined outcome predictors in intensive outpatient programs (IOP). The current study aimed to replicate findings from randomized controlled research trials and inpatient samples, identifying treatment outcome predictors in a transdiagnostic ED IOP sample. METHOD: The current sample comprised 210 consecutive unique IOP patient admissions who received evidence-based ED treatment, M(SD)Duration = 15.82 (13.38) weeks. Weekly patient measures of ED symptoms and global functioning were obtained from patients' medical charts. RESULTS: In relative weight analysis, RR was the only significant predictor of ED symptoms post treatment, uniquely accounting for 45.6% of the predicted variance in ED symptoms. In contrast, baseline ED pathology was the strongest unique predictor of end-of-treatment global functioning, accounting for 15.89% of predicted variance. Baseline factors did not differentiate patients who made RR from those who did not. CONCLUSIONS: Consistent with findings in more controlled treatment settings, RR remains a robust predictor of outcome for patients receiving IOP-level treatment for EDs. Future work should evaluate factors that mediate and moderate RR, incorporating these findings into ED treatment design and implementation. LEVEL OF EVIDENCE: Level IV, uncontrolled intervention.

Practitioners' perspectives on ethical issues within the treatment of eating disorders: Results from a concept mapping study.

OBJECTIVE: Treating patients with eating disorders (EDs) is associated with an array of ethical concerns, including balancing patients' health and autonomy, access to care, and use of harm-reduction versus recovery-oriented treatment models. The primary aim of the current study is to gain a better understanding of ethical issues faced by ED practitioners by using a concept mapping, or Q-sort, approach. METHOD: A total of 12 practitioners completed the brainstorming phase and generated statements regarding ethical issues they faced while treating patients with EDs. A subsequent 38 practitioners completed a sorting task, where they created and labeled piles, into which they grouped each statement. Of those 38 participants, 30 rated both the frequency with which they encountered each ethical issue and its impact on patient care. RESULTS: A total of six clusters emerged: Insufficient Level of Care, Lack of Evidence-Based Practice, Insurance Barriers, Family Involvement, Patient Autonomy, and Limited Access to Expertise. Lack of Evidence-Based Practice, Insurance Barriers, and Insufficient Level of Care was the most frequent problem faced by ED practitioners, whereas Insurance Barriers and Patient Autonomy had the greatest impact. DISCUSSION: Findings outline frequent and impactful areas of ethical concern that arise when treating patients diagnosed with EDs. Practitioners most commonly reported that patient- and insurance-driven factors limited patient access to appropriate care. Regulations supporting the provision of evidence-based care should be emphasized in public health policy and advocacy efforts, given their impact in limiting the delivery of adequate patient care.