Detection of feigned ADHD in college students

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.

Review of Statistical and Methodological Issues in the Forensic Prediction of Malingering from Validity Tests: Part II-Methodological Issues

Forensic neuropsychological examinations to detect malingering in patients with neurocognitive, physical, and psychological dysfunction have tremendous social, legal, and economic importance. Thousands of studies have been published to develop and validate methods to forensically detect malingering based largely on approximately 50 validity tests, including embedded and stand-alone performance and symptom validity tests. This is Part II of a two-part review of statistical and methodological issues in the forensic prediction of malingering based on validity tests. The Part I companion paper explored key statistical issues. Part II examines related methodological issues through conceptual analysis, statistical simulations, and reanalysis of findings from prior validity test validation studies. Methodological issues examined include the distinction between analog simulation and forensic studies, the effect of excluding too-close-to-call (TCTC) cases from analyses, the distinction between criterion-related and construct validation studies, and the application of the Revised Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) in all Test of Memory Malingering (TOMM) validation studies published within approximately the first 20 years following its initial publication to assess risk of bias. Findings include that analog studies are commonly confused for forensic validation studies, and that construct validation studies are routinely presented as if they were criterion-reference validation studies. After accounting for the exclusion of TCTC cases, actual classification accuracy was found to be well below claimed levels. QUADAS-2 results revealed that extant TOMM validation studies all had a high risk of bias, with not a single TOMM validation study with low risk of bias. Recommendations include adoption of well-established guidelines from the biomedical diagnostics literature for good quality criterion-referenced validation studies and examination of implications for malingering determination practices. Design of future studies may hinge on the availability of an incontrovertible reference standard of the malingering status of examinees.

Detecting Attention Deficit Hyperactivity Disorder and its feigning using the Personality Assessment Inventory

Attention Deficit Hyperactivity Disorder is a relatively common and often disabling disorder in adults. However, feigning ADHD symptomatology is both easy and potentially common. We explored the most effective strategies for A) identifying individuals who had been diagnosed with ADHD based on existing PAI symptom indicators, and B), discriminating between feigned and genuine ADHD symptoms using PAI negative distortion indicators. Our sample consisted of 463 college aged participants who had been diagnosed with ADHD (n = 60), were asked to feign ADHD (n = 71), and a control group (n = 333). Self-reported diagnosis and successful feigning were corroborated by the CAARS-S: E scale. We first compared two PAI-derived ADHD indicators to determine which best differentiated between our ADHD and Control groups. Next, we compared seven negative distortion indicators to determine which could best distinguish between real and feigned ADHD symptoms. Our results revealed that the PAI-ADHD scale was the most effective symptom indicator. Further, the Negative Distortion Scale (NDS) and the Item-FAA scale were the most effective for identifying feigners. When assessing ADHD based on the PAI, the PAI-ADHD scale appears promising as an indicator of symptomatology, while the NDS and Item-FAA appear useful to rule-out feigning.

Differentiating depression using facial expressions in a virtual avatar communication system

Depression has a major effect on the quality of life. Thus, identifying an effective way to detect depression is important in the field of human-machine interaction. To examine whether a combination of a virtual avatar communication system and facial expression monitoring potentially classifies people as being with or without depression, this study consists of three research aims; 1) to understand the effect of different types of interviewers such as human and virtual avatars, on people with depression symptoms, 2) to clarify the effect of neutral conversation topics on facial expressions and emotions in people with depression symptoms, and 3) to compare verbal and non-verbal information between people with or without depression. In this study, twenty-seven participants—fifteen in the control group and twelve in the depression symptoms group—were recruited. They were asked to talk to a virtual avatar and human interviewers on both neutral and negative conversation topics and to score PANAS; meanwhile, facial expressions were recorded by a web camera. Facial expressions were analyzed by both manual and automatic analyses. In the manual analysis, three annotators counted gaze directions and reacting behaviors. On the other hand, automatic facial expression detection was conducted using OpenFace. The results of PANAS suggested that there was no significance between different interviewers’ types. Furthermore, in the control group, the frequency of look-downward was larger in negative conversation topics than in neutral conversation topics. The intensity of Dimpler was larger in the control group than in the depression symptoms group. Moreover, the intensity of Chin Raiser was larger in neutral conversation topics than in negative conversation topics in the depression symptoms group. However, in the control groups, there was no significance in the types of conversation topics. In conclusion, 1) there was no significance between human and virtual avatar interviewers in emotions, facial expressions, and eye gaze patterns, 2) neutral conversation topics induced less negative emotion in both the control and depression symptoms group, and 3) different facial expressions’ patterns between people with, or without depression, were observed in the virtual avatar communication system.

Conner's Continuous Performance Test and Adult ADHD: A Systematic Literature Review

OBJECTIVE

ADHD is a neurodevelopmental disorder affecting millions of adults worldwide. Continuous performance tests (CPTs) are widely used as assessment and diagnostic tools; however, their use in diagnosing undiagnosed ADHD in adults has been questioned due to their lack of specificity and sensitivity. This review sought to outline relevant findings concerning the diagnostic utility of the Conner's Continuous Performance Test (CCPT) in adults.

METHOD

This systematic review followed the a priori guide outlined by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Articles were gathered from PsycINFO, PsycArticles, Cochrane, Scopus, Google Scholar, and PubMed.

RESULTS

Thirty-five articles were reviewed and analyzed. Most articles reviewed used outpatient and university populations. Moderate reliability, subpar discriminant and ecological validity, and mixed sensitivity and specificity were noted.

CONCLUSION

The results of this review lend support to previous critiques of the CCPT's diagnostic and utility as a treatment measure.

Accommodation Decision-Making for Postsecondary Students with ADHD: Treating the Able as Disabled

Students with attention-deficit/hyperactivity disorder (ADHD) may be entitled to academic accommodations in postsecondary education. Disability Services Offices (DSOs) in Canada say that objective evidence of functional impairment is required prior to providing academic accommodations. This study set out to determine if postsecondary disability service providers use objective, third-party data when making accommodation decisions. Providers were asked if they would grant extra time accommodations to a fictitious prospective student. The student self-reported attention and academic problems that emerged during COVID restrictions, and that extra time helped her earn better grades and reduced her anxiety. While her neuropsychological report suggested superficial similarity to ADHD and contained accommodation recommendations, it lacked any objective evidence supporting either an ADHD diagnosis or functional impairments that would support extra time accommodation. Despite the lack of current or historical functional impairment, 100% of all DSO decision makers confirmed that they would grant extra time accommodations to this student. Results suggest that DSOs’ accommodation decisions are not based on evidence of functional impairment but rely mainly on student self-report and the recommendations of a professional. As such, the current system of determining reasonable accommodations is flawed and inequitable, offering non-impaired individuals access to supports and services that may privilege them over their similarly abled peers. Postsecondary institutions must either develop more defensible methods of disability determination or provide all students with access to accommodations to create a more equitable learning environment.

Detecting feigned ADHD in college students using the Minnesota multiphasic personality inventory-2-restructured form (MMPI-2-RF)

Objective: To investigate the utility of the validity scales of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) for detecting feigned Attention-Deficit Hyperreactivity Disorder (ADHD), we utilized a simulation design. Method: We examined group differences across the Restructured Clinical (RC) and validity scales as well as the classification ability of the validity scales across three cut scores. Analyses were conducted across five simulation groups (N = 177) and a standard instruction group (N = 32). Results: Across most of the RC and validity scales, those feigning ADHD produced significantly higher scores than the standard instruction group, but generally no significant differences between the feigning groups were demonstrated. The most promising scales for detecting feigned ADHD were F-r, Fp-r, and Fs at cut scores in the 70 T to 80 T range, respectively. Conclusions: Results support the use of the MMPI-2-RF in ADHD evaluations with scores on F-r, Fs, and Fp-r being particularly useful in detecting feigned ADHD in college students. However, there was no evidence to support the feigning of distinct ADHD symptoms presentations.

Malingering and Stimulant Medications Abuse, Misuse and Diversion

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that interferes with multiple aspects of daily functioning. Malingering or feigning of symptoms can be a major challenge during ADHD assessment. Stimulant medication abuse, misuse and diversion may constitute another challenge during management. A literature search of the past 15 years on the topic continued to suggest that there are several reasons for malingering and faking ADHD symptoms. Some of the reasons include the intent to obtain prescriptions for stimulant medications for performance enhancement, to gain access to additional school services and accommodations, to use recreationally and to sell as a street drug. In some countries, patients may receive additional tax or student loan benefits. Several researchers suggested that self-report rating measures are easily simulated by patients without ADHD. They concluded that no questionnaire has proved sufficiently robust against false positives. Some clinical factors that may suggest malingering during the ADHD assessment are highlighted and some available tests to detect malingering are discussed.

Do we over-diagnose ADHD in North America? A critical review and clinical recommendations

There has been a marked increase in the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the last 25 years in North America. Some see this trend as positive and believe that it reflects a better identification of ADHD and even think that the disorder is still under-diagnosed. Others, however, contend that ADHD is over-diagnosed. To help mental health clinicians to maintain an informed and nuanced perspective on this debate, this critical review aims to (1) summarize empirical results on factors that might contribute to increase the number of ADHD diagnoses and (2) propose clinical recommendations coherent with these findings to improve clinical practices for ADHD assessment and treatment. We conclude that artifactual factors such as current formulation of diagnostic criteria, clinical practices, and inordinate focus on performance, which is rampant in North America, likely contribute to inflated prevalence rates.

Feigning Symptoms to Obtain Prescription Stimulants: A Vignette-Based Study on Its Conditions

This vignette-based study examined the willingness to feign symptoms to obtain a prescription following an analysis on who might use prescription stimulants to enhance performance ( N = 3,468). It experimentally manipulated three factors: the social disapproval of prescription stimulant use for enhancement purposes, the physicians’ diagnostic efforts, and the medical condition (attention-deficit/hyperactivity disorder and narcolepsy); respondent characteristics of self-control, personal morality, and self-efficacy were also measured. Our results showed that social disapproval of prescription drug use, a personal morality that disapproves of drug use, high self-control, and high self-efficacy were negatively associated with the willingness to use. Willingness increased especially in situations of social approval when there was a stronger personal approval of drug use, or surprisingly when physicians’ diagnostic efforts were higher. The feigning willingness was lower in situations of social disapproval and when personal morality disapproved of feigning. Thus, personal and situational characteristics are relevant to understand both behaviors.

The Multidimensional ADHD Rating Scale: A measure of symptoms, impairment, and symptom validity

Objective: Two studies examined the psychometric properties of the Multidimensional ADHD Rating Scale (MARS), which assesses ADHD symptoms, related functional impairment, and symptom validity (SV). Method: Study 1 used MARS item responses from college students with and without ADHD (with some of the latter group assigned to feign ADHD) to create an SV-index, and to identify optimal cut scores for the clinical (symptom and impairment) indexes. Study 2 cross-validated the findings on a new sample. Results: In both studies, malingerers reported more symptoms and impairment than participants with ADHD, who reported more symptoms and impairment than controls. Receiver operating characteristic analyses found very good discrimination of genuine ADHD from control cases by the clinical MARS indexes, and very good discrimination of genuine ADHD from malingered ADHD by the SV-index. Conclusion: This research provides initial support for the effectiveness of the MARS to detect simulated cases of malingering, and to differentiate ADHD from non-ADHD cases in college students.

ADHD in University Settings: Predictive Validity of Quantitative EEG Coherence

PURPOSE

Research has demonstrated distinct patterns of electroencephalography (EEG) coherence with attention-deficit/hyperactivity disorder (ADHD) in children; however, few studies have examined coherence measures in adults with ADHD. Further, specific research examining EEG coherence within the subgroup of young adults in post-secondary education is absent from the literature.

METHODS

The current study investigated the utility of quantitative EEG in predicting ADHD behavioral symptoms in 35 college students with a documented ADHD diagnosis and 35 control students.

RESULTS

Increased interhemispheric frontal beta-wave coherence was found in individuals with ADHD. Logistic regression of principle components of quantitative EEG coherence metrics predicted ADHD group membership.

CONCLUSIONS

Suggestions for improving ADHD identification in college populations using quantitative EEG are discussed.

What can we learn about performance validity from TOVA response profiles?

Given the functional impairments associated with Attention Deficit/Hyperactivity Disorder (AD/HD), a valid diagnosis is important. However, particularly when carried out in adulthood, the diagnostic process can be challenging and is complicated by conclusive evidence that a proportion of individuals referred for evaluation of AD/HD exaggerate or feign their symptoms. Relatively few methods, however, exist to identify such feigning. While continuous performance tests (CPTs) may provide useful information regarding performance validity, the question remains as to whether there are consistent patterns of exaggeration demonstrated by those feigning AD/HD. Thus, this study used cluster analysis to determine whether valid and reliable performance clusters would emerge based on CPT performance. Using archival data from a university-based AD/HD screening clinic, we investigated the performance of 305 adults on the Test of Variables of Attention (TOVA). Three profiles emerged, including one cluster who demonstrated exceptionally low performance on the TOVA, exceptionally high reports of AD/HD symptomology, and higher rates of failure on symptom and performance validity tests. The implication from our analysis is that this group most likely represents individuals who were exaggerating or magnifying their difficulties. The results reaffirm previous research showing that performance profiles on a continuous performance test can be used as an indicator of credible performance.

Empirically-informed guidelines for first-time adult ADHD diagnosis

INTRODUCTION

Adult Attention Deficit/Hyperactivity Disorder (ADHD) is prone to misdiagnosis because its symptoms are subjective, share features with a broad range of mental, behavioral and physical disorders, and express themselves heterogeneously. Furthermore, Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for adult ADHD diagnosis remain underdeveloped, prompting a need for systematic and empirically-informed guidelines.

METHOD

This article presents a brief history of research on adult ADHD and reviews common sources of false positive and false negative diagnoses. A systematic, stepped diagnostic procedure is described that adheres to DSM guidelines and integrates the latest science on adult ADHD assessment and diagnosis.

RESULTS

Seven steps are recommended: a structured diagnostic interview with the patient, collection of informant ratings, casting a wide net on symptoms using "or rule" to integrate informant reports, providing checks and balances on the "or rule" by enforcing the impairment criterion, chronicling a symptom timeline, ruling out alternative explanations for symptoms, and finalizing the diagnosis.

CONCLUSIONS

Based on the extant research, it is expected that the stepped diagnostic procedure will increase detection of malingering, improve diagnostic accuracy, and detect non-ADHD cases with subclinical difficulties or non-ADHD pathologies.

Detection of Feigned ADHD Using the MOXO-d-CPT

Objective: The objective of this study was to assess the MOXO-d-CPT utility in detecting feigned ADHD and establish cutoffs with adequate specificity and sensitivity. Method: The study had two phases. First, using a prospective design, healthy adults who simulated ADHD were compared with healthy controls and ADHD patients who performed the tasks to the best of their ability (n = 47 per group). Participants performed the MOXO-d-CPT and an established performance validity test (PVT). Second, the MOXO-d-CPT classification accuracy, employed in Phase 1, was retrospectively compared with archival data of 47 ADHD patients and age-matched healthy controls. Results: Simulators performed significantly worse on all MOXO-d-CPT indices than healthy controls and ADHD patients. Three MOXO-d-CPT indices (attention, hyperactivity, impulsivity) and a scale combining these indices showed adequate discriminative capacity. Conclusion: The MOXO-d-CPT showed promise for the detection of feigned ADHD and, pending replication, can be employed for this aim in clinical practice and ADHD research.

Accommodation decision-making for postsecondary students with ADHD: Implications for neuropsychologists

Neuropsychologists are often asked to evaluate students for attention-deficit/hyperactivity disorder (ADHD) and to provide documentation to support their requests for academic accommodations in college. Research points to the importance of multi-method, multi-informant data when evaluating ADHD and determining the need for accommodations. However, the Association on Higher Education and Disability (AHEAD) directs disability service providers to give primacy to students' self-reports and their own impressions of students' narratives over objective, third-party data when rendering accommodation decisions. The organization asserts that in many cases information from parents, teachers, and psychologists is not needed to confirm the existence of a disability or students' need for accommodations. In this article, we describe the way disability service providers are directed to evaluate accommodation requests, the limitations of these procedures, and the dangers of well-intentioned, but indiscriminate accommodation-granting. We then provide recommendations for neuropsychologists who conduct ADHD evaluations for college students in light of these professional guidelines.

Concordance between the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and Clinical Assessment of Attention Deficit-Adult (CAT-A) over-reporting validity scales for detecting invalid ADHD symptom reporting

This study investigated the relationship between symptom validity scales on the Clinical Assessment of Attention Deficit-Adult (CAT-A) and the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in the context of Attention-Deficit/Hyperactivity Disorder (ADHD) evaluation. The sample comprised 140 consecutive patients referred for a neuropsychological evaluation of ADHD and were administered the CAT-A and the MMPI-2-RF and a battery of performance-based neurocognitive tests. Results indicated CAT-A/MMPI-2-RF symptom validity concordance of 51% between measures, with 38% concordant valid and 13% concordant invalid responses. Among those with discordance symptom validity results, rates of valid CAT-A/invalid MMPI-2-RF responding (41%) were more common than invalid CAT-A/valid MMPI-2-RF responding (8%). Results also indicated higher levels of ADHD symptoms among invalid responding within the CAT-A, whereas the MMPI-2-RF Cognitive Complaints scale did not differ by CAT-A validity status. Finally, symptom validity scales on both the CAT-A and MMPI-2-RF were largely discordant from neuropsychological test validity status per performance validity tests. Findings highlight the need for symptom validity testing when assessing ADHD and indicate that validity indices on broad personality assessments may assess different constructs than embedded validity indices in ADHD-specific measures.

Rates of Performance Validity Test Failure for ADHD Evaluations in a Military Population: An Exploratory Study

Objective: Investigate rates of Performance Validity Test (PVT) failures in a group of active duty (AD) military participants referred for ADHD evaluations and other characteristics of those referred for evaluation. Method: AD service members referred for ADHD evaluations were given PVTs as part of assessment. PVT pass/fail groups were compared on age, estimated premorbid intelligence, history of ADHD, other mental health problems, and functional impairment. Results: PVT failure rate was consistent with other studies. Fail group was younger and lower estimated premorbid intelligence than those that passed. Groups based on other variables did not significantly differ. Failure group also performed worse on a measure of attention. Many individuals were referred with no childhood history of ADHD or objective evidence of impaired function. Conclusion: Rates of PVT failures were similar to those found in civilian university and veteran military settings. Screening candidates for specific Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria for ADHD was only minimally followed.

Profiles of Diagnosed and Undiagnosed College Students Meeting ADHD Symptom Criteria

Objective: This study compared the psychological profiles of college students who self-reported an ADHD diagnosis in contrast to students without a diagnosis who reported above-threshold ADHD symptoms. Method: A large sample of college students yielded four subgroups: students with a self-reported diagnosis who met symptom criteria (Diagnosed, n = 40), students with a self-reported diagnosis who did not meet symptom criteria (Low Symptoms, n = 47), students who had no diagnosis and did not meet symptom criteria (Controls, n = 87), and students who had no diagnosis yet met symptom criteria (Undiagnosed, n = 38). All participants completed a battery of self-report rating scales assessing a variety of symptom and impairment domains. Results: The Diagnosed and Undiagnosed groups differed significantly from Controls on all domains, while the Low Symptom group did not differ significantly from Controls in any domain. Conclusion: Implications for engaging with reported diagnosis of ADHD in the college population are discussed.

A comparison of the self-report patterns of analog versus real-world malingerers of attention deficit hyperactivity disorder

Much of what we know about malingering of attention deficit hyperactivity disorder (ADHD) has been learned from the performance of analog malingerers, typically first-year psychology students given credit for study participation. It is not clear, however, whether their performance is similar to that found in actual clinical settings. Indeed, past research suggests that analog malingerers may overexaggerate deficits relative to real-world malingerers, making them easier to identify in controlled studies. The purpose of the current study was, therefore, to compare the performance of analog malingers to post-secondary students strongly suspected of malingering ADHD on a self-report measure of ADHD symptoms. Their scores were, in turn, compared to those returned by students with genuine ADHD and clinical controls. Results demonstrated that, apart from analog subjects overexaggerating symptoms of hyperactivity, few differences exist between the scores returned by analog malingerers relative to clinical malingerers. While newly devised symptom validity measures show promise in identifying malingered ADHD, neither the analog nor the clinical malingers consistently failed these symptom validity scales. Furthermore, a good portion in both malingering groups failed to endorse high levels of ADHD symptoms in general. Clinical implications are discussed.

Detecting feigned symptoms of depression, anxiety, and ADHD, in college students with the structured inventory of malingered symptomatology

Objective: Research consistently shows how easily students can feign symptoms of ADHD on self-report checklists to determine eligibility for curricular and standardized testing accommodations. However, it is unclear how easily students can feign psychological symptoms to accesses academic accommodations, making the assessment of symptom validity important in both populations.Method: Using a between-subjects design, 75 college students were randomly assigned to one of three groups: (1) coached feigning of ADHD, (2) coached feigning of depression and anxiety (DA), and (3) honest responding (HR). Participants completed the Depression, Anxiety, and Stress Scale (DASS-21) and the Structured Inventory of Malingered Symptomatology (SIMS).Results: The SIMS showed 100% specificity, but low sensitivity (36-52%) for detecting feigned symptoms with different cutoffs. Differences on SIMS subtests were apparent by group with elevated scores for the DA group on the Affective Disorders subscale and elevation for the ADHD group on the Low Intelligence and Amnestic subscales. Participants identified as feigning by the SIMS typically reported more severe symptoms than participants not identified on the DASS-21.Conclusions: The SIMS equally classified the feigned ADHD and DA participants for both cutoff scores utilized. Potential reasons for low sensitivity rates are discussed and future research recommendations are made.

Prevalence of ADHD symptom malingering, nonmedical use, and drug diversion among college-enrolled adults with a prescription for stimulant medications

Malingering of ADHD symptoms is a potential means of nonmedical use of prescription stimulants (NMUPS). The Subtle ADHD Malingering Screener (SAMS) provides a potential avenue for identification of symptom malingering. However, no real world evidence of this scale has been published to date. The goal of this study was to examine patterns of use of stimulant prescriptions and to evaluate the ability of the SAMS to identify NMUPS. This study employed a cross-sectional observational design to administer an online, self-administered survey instrument in a convenience sample of college-enrolled young adults with a prescription for stimulant medications at a campus pharmacy. Respondents were asked about their prescription characteristics, nonmedical use and drug diversion behavior, along with ratings on the SAMS. Over 33% of respondents self-reported past-year NMUPS and 18% reported past-year drug diversion. Over 35% of respondents rated NMUPS as being slight or no risk and 55% were classified by the SAMS as likely to be malingering or exaggerating their symptoms. Individuals reporting past-year NMUPS or diversion consistently scored higher on the SAMS. The SAMS showed potential for future application in the pharmacy setting. Further research is needed to evaluate the relationship of SAMS to NMUPS or drug diversion. The results of this study also highlight several growing issues with the diagnosis and treatment of ADHD among young adults enrolled in college. Addressing perception of risk, social norms, and providing healthcare professionals with tools to prevent misdiagnosis is critical to the management of this issue.

Discriminating malingered attention Deficit Hyperactivity Disorder from genuine symptom reporting using novel Personality Assessment Inventory validity measures

It is now widely understood that ADHD can be feigned easily and convincingly. Despite this, almost no methods exist to assist clinicians in identifying when such behavior occurs. Recently, new validity indicators specific to feigned ADHD were reported for the Personality Assessment Inventory (PAI). Derived from a logistic regression, these algorithms are said to have excellent specificity and good sensitivity in identifying feigned ADHD. However, these authors compared those with genuine ADHD only to nonclinical undergraduate students (asked to respond honestly or asked to simulate ADHD); no criterion group of definite malingerers was included. We therefore investigated these new validity indicators with 331 postsecondary students who underwent assessment for possible ADHD and compared scores of those who were eventually diagnosed with ADHD (n = 111) to those who were not [Clinical controls (66), Definite malingerers (36); No diagnosis (117)]. The two proposed PAI algorithms were found to have poor positive predictive value (.19 and .17). Self-report validity measures from the Connors' Adult Attention Rating Scale, and the Negative Impression Management scale on the PAI returned more positive results. Overall, more research is needed to better identify noncredible ADHD presentation, as the PAI-based methods proposed by Aita et al. appear inadequate as symptom validity measures.

Diagnosing Attention-Deficit/Hyperactivity Disorder (ADHD) in young adults: A qualitative review of the utility of assessment measures and recommendations for improving the diagnostic process

Objective: Identify assessment measures that augment the clinical interview and improve the diagnostic accuracy of adult ADHD assessment.Method: The sometimes limited research literatures concerning the diagnostic efficacies of the clinical interview, standard and novel ADHD behavior rating scales, performance and symptom validity testing, and cognitive tests are critically reviewed.Results: Based on this qualitative review, both clinical interviews alone and ADHD behavior rating scales alone have adequate sensitivity but poor specificity in diagnosing ADHD. Response validity and symptom validity tests have reasonably good sensitivity and very good specificity in detecting invalid symptom presentation. Cognitive test batteries have inadequate sensitivity and specificity in identifying ADHD. Using cognitive tests in conjunction with behavior rating scales significantly improves the specificity of an assessment battery. Executive function behavior rating scales and functional impairment rating scales are unlikely to improve the diagnostic accuracy of ADHD assessment.Conclusions: Based on this review, key clinical interview questions, behavior rating scales, symptom validity tests, and cognitive tests that have promise to enhance current assessment practices are recommended. These are the authors' personal opinions, not consensus standards, or guidelines promulgated by any organization. These measures are incorporated in a practical, somewhat abbreviated, battery that has the potential to improve clinicians' ability to diagnose adult ADHD.

Assessment of Adult ADHD With College Students

Objective: When assessing adult ADHD, self-report measures are commonly used to guide clinical diagnosis. Self-report measures may be broadband covering a range of behaviors or narrowband and specific to symptoms associated with ADHD. Method: This study examined the results of broadband and narrowband measures for college students referred for evaluation of ADHD at a university clinic. Results: With consideration of diagnosis, which included additional information, the group of students who received a diagnosis of ADHD differed significantly from those who did not receive an ADHD diagnosis only on the symptom sets associated with ADHD for both the broadband and narrowband. At the same time, for the total sample, significant correlations emerged for ADHD symptoms with social stress, anxiety, and sense of inadequacy. Conclusion: This suggests the need for consideration of alternative or co-occurring factors influencing symptom presentation and functional impairment.

Clinical utility of WAIS-IV 'excessive decline from premorbid functioning' scores to detect invalid test performance following traumatic brain injury

Objective: Excessive Decline from Premorbid Functioning (EDPF), an atypical discrepancy between demographically predicted and obtained Wechsler Adult Intelligence Scale-4th Edition (WAIS-IV) scores, has been recently proposed as a potential embedded performance validity test (PVT). This study examined the clinical utility of EDPF scores to detect invalid test performance following traumatic brain injury (TBI).Methods: Participants were 194 U.S. military service members who completed neuropsychological testing on average 2.4 years (SD = 4.0) following uncomplicated mild, complicated mild, moderate, severe, or penetrating TBI (Age: M = 34.0, SD = 9.9). Using TBI severity and PVT performance (i.e., PVT Pass/Fail), participants were classified into three groups: Uncomplicated Mild TBI-PVT Fail (MTBI-Fail; n = 21), Uncomplicated Mild TBI-PVT Pass (MTBI-Pass; n = 94), and Complicated Mild to Severe/Penetrating TBI-PVT Pass (CM/STBI-Pass; n = 79). Seven EDPF measures were calculated by subtracting WAIS-IV obtained index scores from the demographically predicted scores from the Test of Premorbid Functioning (TOPF). Cutoff scores to detect invalid test performance were examined for each EDPF measure separately.Results: The MTBI-Fail group had higher scores than the MTBI-Pass and CM/STBI-Pass groups on five of the seven EDPF measures (p<.05). Overall, the EDPF measure using the Processing Speed Index (EDPF-PSI) was the most useful score to detect invalid test performance. However, sensitivity was only low to moderate depending on the cutoff score used.Conclusions: These findings provide support for the use of EDPF as an embedded PVT to be considered along with other performance validity data when administering the WAIS-IV.

The Coin in Hand-Extended Version: Development and Validation of a Multicultural Performance Validity Test

The number of computerized and reliable performance validity tests are scarce. This study aims to address this issue by validating a free and computerized performance validity test: the Coin in Hand-Extended Version (CIH-EV). The CIH-EV test was administered in four countries (Colombia, Spain, Portugal, and the United States) and performance was compared with other commonly used validated tests. Results showed that the CIH-EV has at least 95% specificity and 62% sensitivity, and performance was highly correlated with scores on the Test of Memory Malingering, Victoria Symptom Validity Test, and Digit Span of the Wechsler Adult Intelligence Scale. There were no significant differences in scores across countries, suggesting that the CIH-EV performs similarly in a variety of cultures. Our findings suggest that the CIH-EV has the potential to serve as a valid validity test either alone or as a supplement to other commonly used validity tests.

University students with attention deficit hyperactivity disorder (ADHD): a literature review

OBJECTIVES

To review existing literature about university students with Attention Deficit Hyperactivity Disorder (ADHD).

METHODS

A framework for scoping studies and content analysis were used to source and review selected publications from PubMed, ScienceDirect, Google Scholar and relevant bibliographies.

RESULTS

Seventy-four publications were reviewed and key findings were categorised under six core themes that represent the issues germane to university students with ADHD. These themes are: academic, social and psychological functioning, giftedness, new media technologies, treatment, substance misuse and the non-medical use of prescription stimulants, and malingering.

CONCLUSION

In Ireland and the United Kingdom (UK) young people with ADHD are unlikely to enrol into further education, and of those who do go to university, few will graduate at the same time as their non-ADHD peers. ADHD is associated with poor educational outcomes and it may be a hidden disability within institutions of higher education (e.g. universities). Surprisingly, in this topic area, there is a paucity of research in Ireland and the UK. Most studies originate from North America were research activity in the field has been ongoing since the 1990s. These studies however, tend to use relatively small samples of college (university) students recruited at a single institution. It is difficult to generalise the findings of these studies to student populations in North America, let alone in Ireland and the UK. At the very least, these North American studies provide insights into key areas of concern. This topic area straddles education and psychiatry. This means an inter-disciplinary approach is required to examine, better understand and address the impact of ADHD on the educational outcomes of university students. The philosophies of difference, equity and self-realisation can offer a conceptual framework for conducting further research and/or developing services to deliver more personalised learning support for university students with ADHD.

Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016

BACKGROUND

Stimulants are considered the first-line treatment for Attention Deficit Hyperactivity Disorder (ADHD) in the US and they are used in other indications. Stimulants are also diverted for non-medical purposes. Ethnic and regional differences in ADHD diagnosis and in stimulant use have been identified in earlier research. The objectives of this report were to examine the pharmacoepidemiological pattern of these controlled substances over the past decade and to conduct a regional analysis.

METHODS

Data (drug weights) reported to the US Drug Enforcement Administration's Automation of Reports and Consolidated Orders System for four stimulants (amphetamine, methylphenidate, lisdexamfetamine, and methamphetamine) were obtained from 2006 to 2016 for Unites States/Territories. Correlations between state level use (mg/person) and Hispanic population were completed.

RESULTS

Amphetamine use increased 2.5 fold from 2006 to 2016 (7.9 to 20.0 tons). Methylphenidate use, at 16.5 tons in 2006, peaked in 2012 (19.4 tons) and subsequently showed a modest decline (18.6 tons in 2016). The consumption per municipality significantly increased 7.6% for amphetamine and 5.5% for lisdexamfetamine but decreased 2.7% for methylphenidate (all p < .0005) from 2015 to 2016. Pronounced regional differences were also observed. Lisdexamfetamine use in 2016 was over thirty-fold higher in the Southern US (43.8 mg/person) versus the Territories (1.4 mg/person). Amphetamine use was about one-third lower in the West (48.1 mg/person) relative to the Northeastern (75.4 mg/person, p < .05) or the Midwestern (69.9 mg/person, p ≤ .005) states. States with larger Hispanic populations had significantly lower methylphenidate (r(49) = -0.63), lisdexamfetamine (B, r(49) = -0.49), and amphetamine (r(49) = -0.43) use.

CONCLUSIONS

Total stimulant usage doubled in the last decade. There were dynamic changes but also regional disparities in the use of stimulant medications. Future research is needed to better understand the reasons for the sizable regional and ethnic variations in use of these controlled substances.

Utility of the Personality Assessment Inventory in detecting feigned Attention-Deficit/Hyperactivity Disorder (ADHD): The Feigned Adult ADHD index

Objective

The high potential for secondary gain among college students presenting for Attention-Deficit/Hyperactivity Disorder (ADHD) evaluations highlights the need for psychometrically sound embedded validity indicators. The purpose of this study was to develop new validity indicators specific to feigned ADHD for the Personality Assessment Inventory (PAI) and compare them to preexisting imbedded PAI validity measures.

Method

PAI scales that were theoretically related to feigned ADHD were evaluated. A binomial (ADHD simulators, n = 138, and genuine ADHD, n = 142) logistic regression was conducted with selected PAI scales and subscales. Classification rates were compared between the new and existing validity scales. A similar approach was used for item-level data in a second study in a subgroup of the original sample.

Results

The derived PAI scale-based logistic regression had a sensitivity of 54% and specificity of 92%. This algorithm accurately identified 97% of healthy controls as not feigning ADHD and correctly identified 98% of a no diagnosis group and 75% of a mood/anxiety disorders group. Classification accuracy of the new index was superior to the majority of existing PAI validity scales across groups. An item-level PAI algorithm had a sensitivity of 85% and specificity of 97% for identifying feigned ADHD.

Conclusions

New validity measures were compared to existing PAI validity indicators and performed better than many of them in this study. The algorithms developed in this study of ADHD simulators and genuine ADHD cases have adequate sensitivity and good specificity and appear to function differently than other PAI symptom validity scales.

Family environment moderates the relation of sluggish cognitive tempo to attention-deficit/hyperactivity disorder inattention and depression

OBJECTIVES

The current study investigated whether a maladaptive family environment would moderate the strength of the relations of sluggish cognitive tempo (SCT) to attention-deficit/hyperactivity disorder inattention (ADHD-IN) and to depressive symptoms in a large sample of college students.

METHODS

Participants (n = 3,172), between the ages of 18-29 (M ± SD_age  = 19.24 ± 1.52; 69.8% women; 80.4% White) and enrolled in five universities in the United States completed self-report measures of symptomatology, interparental conflict, and family expressiveness of emotions.

RESULTS

A negative emotional climate strengthened relations of SCT with ADHD-IN and depressive symptoms. Moreover, the lack of a positive emotional climate strengthened the co-occurrence of SCT with depressive symptoms, though not with ADHD-IN.

CONCLUSIONS

The current study is the first to demonstrate that the family environment moderates the association between SCT and co-occurring symptomatology in young adults.

Analysis of cognitive and attentional profiles in children with and without ADHD using an innovative virtual reality tool

In previous studies, children with Attention-Deficit Hyperactivity Disorder (ADHD) have been found to have more difficulties with processing speed, working memory, and attentional tasks. The present study aimed to compare the cognitive variables (working memory and processing speed) and the attentional profiles of a sample of students with and without ADHD, using scales from the WISC-IV, and the virtual reality-based attentional test known as 'Aula Nesplora'; and determine the extent to which the aforementioned variables may predict student group membership. A total of 88 students took part in this study (66 males and 22 females), aged from 6 to 16 years (M = 10.20; SD = 2.79). The sample was divided into two groups: an ADHD group (n = 50) and a Control group (n = 38). Students in the ADHD group obtained lower scores in working memory and in processing speed, as well as demonstrating poorer performance in Aula Nesplora than did their peers. Working memory, and the number of omissions, were both shown to be reliable predictors of group membership. This study revealed the importance of obtaining data from attentional variables differentiated by modality when considering cognitive variables, in order to better characterize the difficulties experienced by individuals diagnosed with ADHD.

Cross-validation of PAI scales for the detection of suspected ADHD in adults

The purpose of this study was to cross-validate scales and subscales of the Personality Assessment Inventory (PAI) identified in previously published research against criterion variables for the identification of Attention Deficit/Hyperactivity Disorder (ADHD) in adults. Performance-based indicators of attention deficits from the Wechsler Adult Intelligence Scale-Fourth Edition were used as criterion variables. In a hierarchical logistic regression analysis, the addition of the PAI scales to the criterion variables did significantly improve the fit of the model, with an overall classification accuracy of 75%. Limitations of this study and implications for future research are discussed.

Sluggish cognitive tempo in adults: Psychometric validation of the Adult Concentration Inventory

[Correction Notice: An Erratum for this article was reported in Vol 30(3) of Psychological Assessment (see record 2017-30273-001). In the article, the Table 1 item content was incorrectly ordered. The table, as well as text referencing Table 1 in the Results and Discussion, have been corrected in all versions of this article.] As interest in sluggish cognitive tempo (SCT) increases, a primary limitation for the field is the lack of a unified set of symptoms for assessing SCT. No existing SCT measure includes all items identified in a recent meta-analysis as optimal for distinguishing between SCT and attention-deficit/hyperactivity disorder (ADHD) inattention. This study evaluates a new self-report measure for assessing SCT in adulthood, the Adult Concentration Inventory (ACI), which was developed in response to the meta-analytic findings for assessing SCT. Using a large, multiuniversity sample (N = 3,172), we evaluated the convergent and discriminant validity and reliability of the ACI. We also evaluated the ACI measure of SCT in relation to self-reported demographic characteristics, daily life executive functioning, socioemotional adjustment (i.e., anxiety/depression, loneliness, emotion dysregulation, self-esteem), and functional impairment. Exploratory confirmatory factor analyses resulted in 10 ACI items demonstrating strong convergent and discriminant validity from both anxiety/depressive and ADHD inattentive symptom dimensions. SCT was moderately to-strongly correlated with daily life EF deficits, poorer socioemotional adjustment, and greater global functional impairment. Moreover, SCT remained uniquely associated in structural regression analyses with most of these external criterion domains above and beyond ADHD. Finally, when internalizing symptoms were also covaried, SCT, but not ADHD inattention, remained significantly associated with poorer socioemotional adjustment. These findings support the use of the ACI in future studies examining SCT in adulthood and make a major contribution in moving the field toward a unified set of SCT items that can be used across studies. (PsycINFO Database Record

Evaluating the consistency of scales used in adult attention deficit hyperactivity disorder assessment of college-aged adults

OBJECTIVE

Neurocognitive evaluations are commonly integrated with clinical assessment to evaluate adult Attention Deficit Hyperactivity Disorder (ADHD). Study goal is to identify measures most strongly related to ADHD diagnosis and to determine their utility in screening processes.

PARTICIPANTS

230 students who were evaluated at the Vanderbilt University Psychological and Counseling Center between July 2013 and October 2015.

METHODS

We retrospectively examined charts, including clinical diagnosis, family history, childhood parental reported and current self-reported ADHD symptoms, psychiatric comorbidities, and continuous performance test (CPT).

RESULT

Positive report of childhood and current ADHD symptoms, and lack of comorbid psychiatric symptoms were strongly associated with clinical diagnosis. CPT results were not associated with an ADHD diagnosis. The absence of reported childhood and current ADHD symptoms may serve as a contradictory marker for ADHD diagnosis.

CONCLUSION

Clinical assessment of ADHD symptoms and ADHD childhood history, but not CPT, contributes to an accurate diagnosis of ADHD in college-aged adults.

Faking ADHD? Symptom Validity Testing and Its Relation to Self-Reported, Observer-Reported Symptoms, and Neuropsychological Measures of Attention in Adults With ADHD

OBJECTIVE

To compare ADHD patients who failed a symptom validity test with those who passed the test to explore whether there are signs of negative response bias on group level.

METHOD

In our outpatient department, 196 adults were diagnosed with ADHD using a comprehensive diagnostic strategy featuring a detailed clinical history, clinical interview, observer rating, several self-rating scales, and neuropsychological attention tests. The Amsterdam Short Term Memory Test (AKGT) was applied as a symptom validity measure.

RESULTS

Sixty-three patients (32.1%) scored below the AKGT cutoff level. The two groups did not significantly differ regarding self-report and observer ratings. Those who failed the AKGT had higher reaction time variabilities in selective, auditory and visual divided attention, and higher omission errors in sustained attention.

CONCLUSION

We found no strong indicators for negative response bias in ADHD patients who failed a symptom validity test. New measures and approaches to detect feigned ADHD should be developed.