Validation of alternative dot counting test E-score cutoffs based on degree of cognitive impairment in veteran and civilian clinical samples.

OBJECTIVE: This study examined Dot Counting Test (DCT) performance among patient populations with no/minimal impairment and mild impairment in an attempt to cross-validate a more parsimonious interpretative strategy and to derive optimal E-Score cutoffs. METHOD: Participants included clinically-referred patients from VA (n = 101) and academic medical center (AMC, n = 183) settings. Patients were separated by validity status (valid/invalid), and subsequently two comparison groups were formed from each sample's valid group. Namely, Group 1 included patients with no to minimal cognitive impairment, and Group 2 included those with mild neurocognitive disorder. Analysis of variance tested for differences between rounded and unrounded DCT E-Scores across both comparison groups and the invalid group. Receiver operating characteristic curve analyses identified optimal validity cut-scores for each sample and stratified by comparison groups. RESULTS: In the VA sample, cut scores of ≥13 (rounded) and ≥12.58 (unrounded) differentiated Group 1 from the invalid performers (87% sensitivity/88% specificity), and cut scores of ≥17 (rounded; 58% sensitivity/90% specificity) and ≥16.49 (unrounded; 61% sensitivity/90% specificity) differentiated Group 2 from the invalid group. Similarly, in the AMC group, a cut score of ≥13 (rounded and unrounded; 75% sensitivity/90% specificity) differentiated Group 1 from the invalid group, whereas cut scores of ≥18 (rounded; 43% sensitivity/94% specificity) and ≥16.94 (unrounded; 46% sensitivity/90% specificity) differentiated Group 2 from the invalid performers. CONCLUSIONS: Different cut scores were indicated based on degree of cognitive impairment, and provide proof-of-concept for a more parsimonious interpretative paradigm than using individual cut scores derived for specific diagnostic groups.

Comparing the Independent and Aggregated Accuracy of Trial 1 and the First 10 TOMM Items for Detecting Invalid Neuropsychological Test Performance Across Civilian and Veteran Clinical Samples.

Previous studies support using two abbreviated tests of the Test of Memory Malingering (TOMM), including (a) Trial 1 (T1) and (b) the number of errors on the first 10 items of T1 (T1e10), as performance validity tests (PVTs). In this study, we examined the independent and aggregated predictive utility of TOMM T1 and T1e10 for identifying invalid neuropsychological test performance across two clinical samples. We employed cross-sectional research to examine two independent and demographically diverse mixed samples of military veterans and civilians (VA = 108; academic medical center = 234) of patients who underwent neuropsychological evaluations. We determined validity groups by patient performance on four independent criterion PVTs. We established concordances between passing/failing the TOMM T1e10 and T1, followed by logistic regression to determine individual and aggregated accuracy of T1e10 and T1 for predicting validity group membership. Concordance between passing T1e10 and T1 was high, as was overall validity (87-98%) across samples. By contrast, T1e10 failure was more highly concordant with T1 failure (69-77%) than with overall invalidity status (59-60%) per criterion PVTs, whereas T1 failure was more highly concordant with invalidity status (72-88%) per criterion PVTs. Logistic regression analyses demonstrated similar results, with T1 accounting for more variance than T1e10. However, combining T1e10 and T1 accounted for the most variance of any model, with T1e10 and T1 each emerging as significant predictors. TOMM T1 and, to a lesser extent, T1e10 were significant predictors of independent criterion-derived validity status across two distinct clinical samples, but they did not offer improved classification accuracy when aggregated.

Assessment of differential neurocognitive performance based on the number of performance validity tests failures: A cross-validation study across multiple mixed clinical samples.

Objective: This cross-sectional study examined the effect of number of Performance Validity Test (PVT) failures on neuropsychological test performance among a demographically diverse Veteran (VA) sample (n = 76) and academic medical sample (AMC; n = 128). A secondary goal was to investigate the psychometric implications of including versus excluding those with one PVT failure when cross-validating a series of embedded PVTs. Method: All patients completed the same six criterion PVTs, with the AMC sample completing three additional embedded PVTs. Neurocognitive test performance differences were examined based on number of PVT failures (0, 1, 2+) for both samples, and effect of number of criterion failures on embedded PVT performance was analyzed among the AMC sample. Results: Both groups with 0 or 1 PVT failures performed better than those with ≥2 PVT failures across most cognitive tests. There were nonsignificant differences between those with 0 or 1 PVT failures except for one test in the AMC sample. Receiver operator characteristic curve analyses found no differences in optimal cut score based on number of PVT failures when retaining/excluding one PVT failure. Conclusion: Findings support the use of ≥2 PVT failures as indicative of performance invalidity. These findings strongly support including those with one PVT failure with those with zero PVT failures in diagnostic accuracy studies, given that their inclusion reflects actual clinical practice, does not reduce sample sizes, and does not artificially deflate neurocognitive test results or inflate PVT classification accuracy statistics.

Cross-validation of a forced-choice validity indicator to enhance the clinical utility of the Rey Auditory Verbal Learning Test.

A forced-choice (FC) recognition trial was recently developed as an embedded validity indicator for the Rey Auditory Verbal Learning Test (RAVLT), although it has not been replicated outside of the initial validation study. This study cross-validated the RAVLT FC trial for detecting invalid neuropsychological test performance and assessed the degree to which material-specific verbal memory impairment severity impacts its classification accuracy as a performance validity test (PVT). This cross-sectional study included 172 neuropsychiatric patients who completed the RAVLT and 4 independent criterion PVTs, which were used to classify validity groups (134 valid/38 invalid). Overall results showed the RAVLT FC had excellent classification accuracy for detecting invalid performance at a ≤13 cut-score (66% sensitivity/87% specificity). When patients were subdivided by memory impairment status, FC retained excellent classification accuracy among the normal memory and mild memory impairment groups with 66%-82% sensitivity and ≥89% specificity. Accuracy decreased among those with severe memory impairment, but remained significant with a lower, alternative cut-score of ≤11 (37% sensitivity/88% specificity). Findings were consistent with FC trials developed for other memory measures and support the utility of this novel RAVLT FC index for reliably identifying invalid performance, even in the context of significant verbal memory impairment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

"I Couldn't Be Better": Assessing Self-Awareness With the Mayo-Portland Adaptability Inventory-4 Following TBI.

INTRODUCTION/OBJECTIVE: To describe level of awareness, as assessed by the Mayo-Portland Adaptability Inventory-4 (MPAI-4), across physical, cognitive, functional, and emotional domains in individuals with mild, moderate, and severe traumatic brain injury (TBI) participating in a residential rehabilitation program. In addition, this study aimed to examine the relationship between time since injury and awareness. A novel way the MPAI-4 can be used to measure self-awareness is also presented. METHOD: Retrospective analysis of existing data. The MPAI-4 was completed by the patient on admission, as well as by provider consensus within 2 weeks of admission. Level of awareness was determined by discrepancy scores, computed as MPAI-4 provider consensus score minus self-report MPAI-4 score, for the total score and for each index score: Ability, Adjustment, and Participation. PARTICIPANTS: A total of 101 military veterans and active duty service members admitted to a Veterans Affairs community reintegration rehabilitation program. RESULTS: Discrepancies between patient and provider reports of functioning were found among all severities of TBI across the MPAI-4 total score and index domains measuring Ability, Adjustment, and Participation. Interestingly, those with mild TBI endorsed greater impairments than their providers, while those with moderate and severe TBI reported less impairment on the MPAI-4 than providers. The effect of time varied across domains, and those who were more than 1 year postinjury displayed greater self-awareness. CONCLUSION: This study highlights the importance of measuring awareness of functional ability over time and across TBI severity and introduces a novel method for doing so, using the MPAI-4 for comparison between staff and patient reports.

Minimizing evaluation time while maintaining accuracy: Cross-validation of the Test of Memory Malingering (TOMM) Trial 1 and first 10-item errors as briefer performance validity tests.

Current standards of practice in neuropsychology advocate for including validity tests (PVTs). Abbreviating PVTs, such as the Test of Memory Malingering (TOMM), may help reduce overall evaluation time while maintaining diagnostic accuracy. TOMM Trial 1 performance (T1), as well as the number of errors within the first 10 items of Trial 1 (TOMMe10), have shown initial promise as abbreviated PVTs but require additional external cross-validation. This study sought to replicate findings from other mixed, diverse, clinical samples and provide further validation of abbreviated administrations of the TOMM. Data included 120 veterans who completed the TOMM and 3 criterion PVTs during clinical evaluation. In total, performance from 68% of the sample was classified as valid (52% met criteria for cognitive impairment), and performance from 32% of the sample was invalid. Group differences, diagnostic accuracy statistics, and receiver operating characteristic (ROC) curves were analyzed for relevant TOMM indices. There were large (η²p= .45-.66), significant differences between validity groups (p < .001) on TOMM T1 and TOMMe10, with lower TOMM T1 and higher TOMMe10 scores for participants with invalid performance. Using established cut-scores, sensitivities/specificities were: TOMMe10 ≥1 error: .84/.66; ≥2 errors: .74/.93; TOMM T1 ≤40: .82/.93. ROC curve analysis yielded significant areas under the curve for both TOMMe10 and T1 with respective optimal cut-scores of ≥2 errors (.74 sensitivity/.93 specificity) and ≤41 (.84 sensitivity/.91 specificity). TOMMe10 and T1 performances are minimally impacted by cognitive impairment. Although both evidenced robust psychometric properties, TOMM T1 continued to show greater accuracy than TOMMe10. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Convergent, Discriminant, and Concurrent Validity of Nonmemory-Based Performance Validity Tests.

To supplement memory-based Performance Validity Tests (PVTs) in identifying noncredible performance, we examined the validity of the two most commonly used nonmemory-based PVTs-Dot Counting Test (DCT) and Wechsler Adult Intelligence Scale-Fourth edition (WAIS-IV) Reliable Digit Span (RDS)-as well as two alternative WAIS-IV Digit Span (DS) subtest PVTs. Examinees completed DCT, WAIS-IV DS, and the following criterion PVTs: Test of Memory Malingering, Word Memory Test, and Word Choice Test. Validity groups were determined by passing 3 (valid; n = 69) or failing ⩾2 (noncredible; n = 30) criterion PVTs. DCT, RDS, RDS-Revised (RDS-R), and WAIS-IV DS Age-Corrected Scaled Score (ACSS) were significantly correlated (but uncorrelated with memory-based PVTs). Combining RDS, RDS-R, and ACSS with DCT improved classification accuracy (particularly for DCT/ACSS) for detecting noncredible performance among valid-unimpaired, but largely not valid-impaired examinees. Combining DCT with ACSS may uniquely assess and best supplement memory-based PVTs to identify noncredible neuropsychological test performance in cognitively unimpaired examinees.

Evaluating the accuracy of the Wechsler Memory Scale-Fourth Edition (WMS-IV) logical memory embedded validity index for detecting invalid test performance.

Embedded performance validity tests (PVTs) allow for continuous assessment of invalid performance throughout neuropsychological test batteries. This study evaluated the utility of the Wechsler Memory Scale-Fourth Edition (WMS-IV) Logical Memory (LM) Recognition score as an embedded PVT using the Advanced Clinical Solutions (ACS) for WAIS-IV/WMS-IV Effort System. This mixed clinical sample was comprised of 97 total participants, 71 of whom were classified as valid and 26 as invalid based on three well-validated, freestanding criterion PVTs. Overall, the LM embedded PVT demonstrated poor concordance with the criterion PVTs and unacceptable psychometric properties using ACS validity base rates (42% sensitivity/79% specificity). Moreover, 15-39% of participants obtained an invalid ACS base rate despite having a normatively-intact age-corrected LM Recognition total score. Receiving operating characteristic curve analysis revealed a Recognition total score cutoff of < 61% correct improved specificity (92%) while sensitivity remained weak (31%). Thus, results indicated the LM Recognition embedded PVT is not appropriate for use from an evidence-based perspective, and that clinicians may be faced with reconciling how a normatively intact cognitive performance on the Recognition subtest could simultaneously reflect invalid performance validity.

Relative impacts of mild and major neurocognitive disorder on rate of verbal learning acquisition.

OBJECTIVE: The California Verbal Learning Test-second edition (CVLT-II) learning slope index may signal the presence of cognitive impairment, though the relative impacts of mild (MiND) and major (MaND) neurocognitive disorders on the rate of verbal learning acquisition remain unknown. METHODS: Latent intercept-only, linear, quadratic, and exponential models were fit to raw scores for the five CVLT-II learning trials of 197 veterans. Dummy-coded variables reflecting MiND and MaND predicted the growth factors. RESULTS: Quadratic growth best fit the data. MiND and MaND predicted reduced recall on each trial. MaND predicted reduced rate of learning acquisition (i.e., word gains per trial) over-and-above MiND, even after controlling for age, sex, education, race/ethnicity, and mono/bilingualism. CONCLUSIONS: Nonlinear growth-with continuous but diminishing gains over trials-best characterized verbal learning acquisition. Reduced word recall each trial may help differentiate MiND from no neurocognitive disorder, while reduced rate of verbal learning acquisition may help differentiate MaND from MiND.

Relax while you rehabilitate: A pilot study integrating a novel, yoga-based mindfulness group intervention into a residential military brain injury rehabilitation program.

OBJECTIVE: This preliminary, pilot study assessed the effectiveness of a group-based, mindfulness intervention in a residential, rehabilitation setting with specific focus on assessing participants' self-report of perceived benefit of the intervention on overall health, pain, sleep, mood/anxiety, attention, and self-awareness, as well as implementing modifications needed for successful intervention application among a diverse, clinical military population. METHOD/DESIGN: Participants were 19 veterans and active duty service members with a history of traumatic brain injury (TBI; 63% severe) who completed a mindfulness-based group intervention during inpatient admission at a Veterans Affairs Polytrauma Transitional Rehabilitation Program (PTRP). Mindfulness and yoga skills were taught in a required, weekly group incorporated into participants' rehabilitation schedule. Opinions and attitudes about mindfulness, as well as pertinent self-report outcome measures, were obtained pre- and postgroup participation. RESULTS: Results suggested that participation in the group was positively associated with individuals' self-reported belief about the benefit of mindfulness in the areas of overall health, physical health, mood, focus, and self-awareness. The more groups attended, the more positive the participants' beliefs about potential impact on overall health and mood became, even while controlling for length of rehabilitation stay. Additionally, several specific group modifications relevant to this population (e.g., physical/environmental modifications, repetition, ignoring/reorienting) were implemented to support successful participation. CONCLUSIONS/IMPLICATIONS: These preliminary and exploratory findings suggest that it may be worthwhile for psychologists, clinicians, and other health care providers working with a mixed TBI population, and more specifically a military population with TBI, to consider introducing mindfulness skills as part of multidisciplinary rehabilitation. (PsycINFO Database Record

The Dot Counting Test adds up: Validation and response pattern analysis in a mixed clinical veteran sample.

OBJECTIVE: This study cross-validated the Dot Counting Test (DCT) as a performance validity test (PVT) among a mixed clinical veteran sample. Completion time and error patterns also were examined by validity group and cognitive impairment status. METHOD: This cross-sectional study included 77 veterans who completed the DCT during clinical evaluation. Seventy-four percent (N = 57) were classified as valid and 26% as noncredible (N = 20) via the Word Memory Test (WMT) and Test of Memory Malingering (TOMM). Among valid participants, 47% (N = 27) were cognitively impaired, and 53% (N = 30) were unimpaired. RESULTS: DCT performance was not significantly associated with age, education, or bilingualism. Seventy-five percent of the overall sample committed at least one error across the 12 stimulus cards; however, valid participants had a 27% higher rate of 0 errors, while noncredible participants had a 35% higher rate of ≥4 errors. Overall, noncredible individuals had significantly longer completion times, more errors, and higher E-scores. Conversely, those with cognitive impairment had longer completion times, but comparable errors to their unimpaired counterparts. Finally, DCT E-scores significantly predicted group membership with 83.1% classification accuracy and an area under the curve of .87 for identifying invalid performance. The optimal cut-score of 15 was associated with 70% sensitivity and 88% specificity. CONCLUSION: The DCT demonstrated good classification accuracy and sensitivity/specificity for identifying noncredible performance in this mixed clinical veteran sample, suggesting utility as a non-memory-based PVT with this population. Moreover, cognitive impairment significantly contributed to slower completion times, but not reduced accuracy.

Neuropsychological Evaluation in Traumatic Brain Injury.

Clinical neuropsychology is a subspecialty of professional psychology that is concerned with the scientific study and clinical application of brain-behavior relationships. Broadly defined, a neuropsychological evaluation is a flexible clinical tool that involves integration of objective, psychometric test data along with various other sources of clinical information to comprehensively elucidate the cognitive, behavioral, and emotional sequelae after traumatic brain injury (TBI). In addition to characterizing TBI sequelae, evidenced-based neuropsychological assessment can contribute to TBI patient care by aiding with prognostic assessment, measuring interval change/recovery over time (eg, resolution of posttraumatic amnesia), informing and implementing rehabilitation strategies, and evaluating the effectiveness of interventions.

Slow and Steady Does Not Always Win the Race: Investigating the Effect of Processing Speed across Five Naming Tests.

OBJECTIVE: This retrospective study investigated the effect of processing speed on confrontation naming performance via five naming tests with varying time components. METHOD: The effect of processing speed, as measured by the Wechsler Adult Intelligence Scale-Fourth Edition Processing Speed Index (PSI), and cognitive impairment were examined using Boston Naming Test, Neuropsychological Assessment Battery Naming Test, Visual Naming Test (VNT), Auditory Naming Test (ANT), and Woodcock-Johnson III Rapid Picture Naming (RPN) performance among a mixed clinical sample of 115 outpatient veterans. RESULTS: PSI scores accounted for 5%-26% of the total variance in naming test performances. Comparison of cognitively impaired versus unimpaired participants found significant differences and medium to large effect sizes (η2 = .08-.20) for all naming measures except ANT tip-of-the-tongue responses. After controlling for the effect processing speed, VNT tip-of-the-tongue responses also became non-significant, whereas significant group differences remained present for all other naming test scores, albeit with notably smaller effects sizes (η2 = .06-.10). CONCLUSIONS: Confrontation naming test performance is related to cognitive processing speed, although the magnitude of this effect varies by the demands of each naming test (i.e., largest for RPN; smallest for VNT). Thus, results argue that processing speed is important to consider for accurate clinical interpretation of naming tests, especially in the context of cognitive impairment.

The effect of perceptual reasoning abilities on confrontation naming performance: An examination of three naming tests.

INTRODUCTION: Confrontation naming tests are a common neuropsychological method of assessing language and a critical diagnostic tool in identifying certain neurodegenerative diseases; however, there is limited literature examining the visual-perceptual demands of these tasks. This study investigated the effect of perceptual reasoning abilities on three confrontation naming tests, the Boston Naming Test (BNT), Neuropsychological Assessment Battery (NAB) Naming Test, and Visual Naming Test (VNT) to elucidate the diverse cognitive functions underlying these tasks to assist with test selection procedures and increase diagnostic accuracy. METHOD: A mixed clinical sample of 121 veterans were administered the BNT, NAB, VNT, and Wechsler Adult Intelligence Scale-4th Edition (WAIS-IV) Verbal Comprehension Index (VCI) and Perceptual Reasoning Index (PRI) as part of a comprehensive neuropsychological evaluation. RESULTS: Multiple regression indicated that PRI accounted for 23%, 13%, and 15% of the variance in BNT, VNT, and NAB scores, respectively, but dropped out as a significant predictor once VCI was added. Follow-up bootstrap mediation analyses revealed that PRI had a significant indirect effect on naming performance after controlling education, primary language, and severity of cognitive impairment, as well as the mediating effect of general verbal abilities for the BNT (B = 0.13; 95% confidence interval, CI [.07, .20]), VNT (B = 0.01; 95% CI [.002, .03]), and NAB (B = 0.03; 95% CI [.01, .06]). CONCLUSIONS: Findings revealed a complex relationship between perceptual reasoning abilities and confrontation naming that is mediated by general verbal abilities. However, when verbal abilities were statistically controlled, perceptual reasoning abilities were found to have a significant indirect effect on performance across all three confrontation naming measures with the largest effect noted with the BNT relative to the VNT and NAB Naming Test.