Consideration of symptom validity as a routine component of forensic assessment, Erin Eggleston

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  • Capture all term.
  • Fitness to plead NZ Parole Board assessments of offending behaviour, risk, change and related issues s333 youth court Assessments of Mental Injury as a consequence of Physical injury or Criminal Act (ACC) Neuropsychological Assessment Eligibility for ID Compulsory Care and Rehab. As my GP medical advisor colleague who I sit next to at ACC says – you psychologists are taking over the world….
  • The power of the Psychologist as change agent may have has been eroded by us becoming involved in such decision making. Informed Consent. Clients may become suspicious of psychologists motives. Will we be considered as agents of the state?
  • See diagnosis of ID and institutionalisation.
  • Forced choice tests…TOMM Lower Sensitivity..test ability to ID actual postives is low High Specificity: proportion of negatives correctly iD. I.e few false positives True positive: Dissimulators correctly identified False positive: Healthy people incorrectly identified as dissimulators True negative: Healthy people correctly identified as healthy False negative: Dissimulators incorrectly identified as healthy.
  • The need for Symptom validity testing is an accepted standard and integral part of the neuropsychological assessment. What about other areas of practice as we have discussed..there are many that fall outside of neurpsychology. There is ample evidence that poor performance on SV tests undermines the confidence that can be placed in the results of Neuropsychological findings. For example… Failure on SVT invalidates the relationship between neuropsychological results and brain damage. (Fox, 2011, The Clinical Neuropsychologist). Sort of important..right?
  • SIRS: MCMI-III…known to correctly classify psychiatric inpatients and known to be only slightly better than chance at identifiying feigned psychopathology MCMI-III (PPP= positive predictive power, NPP=negative predictive power) Scale X raw scores > 178 failed to identify any of the student malingerers, resulting in a PPP of 0 but a hit rate of 63.1% because all of the psychiatric inpatients were correctly classified. Scale X BR score > 89 maximized the validity of decisions based on using a cutoff score to differentiate student malingerers from bona fide psychiatric inpatients. The maximum PPP achieved was 63.8% by Scale X, indicating that when a BR score of 89 was exceeded, the probability that the person was malingering was somewhat better than chance
  • TOMM is probably not best practice for ID…not sure what is. But I think in this case with an FSIQ of <60 , a good pass on the TOMM is impressive.
  • Psychologist made no particular error really..more so the communication of the results was not as clear as it could have been. EG. Using .. What this means is …. RESULTS…performance on the Stanford Binet 5 (SB5) was of overall intelligence in the average range for his age, with an IQ of 90-98 (95% confidence). There were no significant differences favouring verbal (language) or non-verbal intelligence. The profile is consistent was someone with a normal learning trajectory and a knowledge score that was impacted by low exposure to learning opportunities whether in or out of school. There was no evidence of cognitive deficit that would suggest a learning problem, brain injury or disability. - while it is possible to score worse than one’s potential, for various reasons, it is not possible to score better than ones actual ability I did have a forced choice symptom validity measures available but in the end did not need it.
  • Difference between test data and opinion in court is an interesting distinction. Psychology evidence can sometimes be the most robust because of our willingness to test alternative hypotheses.
  • Consideration of symptom validity as a routine component of forensic assessment, Erin Eggleston

    1. 1. Consideration of Symptom Validityas a Routine Component ofForensic Assessment Erin Eggleston PhD DipClinPsych Reg. Clinical Psychologist
    2. 2. What I mean by SymptomValidity….The measurement or observation ofbias in test behaviour and selfreported psychopathology.response biasmotivational inhibition / test underperformancedissimulation / intentional feigningself debasementself enhancement / denial of everyday lifecomplaints/ presenting overly favourablysymptom exaggeration / magnificationsymptom under reporting
    3. 3. What I mean by the forensic… Expert provision of clinical evidence to inform decision making or court proceedings. In New Zealand psychologists have long been used as experts in the Family Court. This type of assessment role is growing as what we can do becomes better understood.
    4. 4. Pitfalls when psychology interfaces with law…“If I talk with you, you’ll find out things aboutme and then the Parole Board will find outand keep me in longer” (offender, abridged)“You Psychologists just say I’m high risk – thatdoesn’t help me. So no I don’t consent”(offender, abridged)
    5. 5. Making the Case…. for knowing about and being able to deliver basic Symptom Validity tests as part of clinical screen in forensic settings. For being willing to test the validity and robustness of our psychological findings Regarding the risks of not being sure about symptom validity.
    6. 6. Incidence  The known base rate internationally for symptom exaggeration in neuropsychological field ranges from 7.5% to 33% in clinical settings.  30-40% in settings where incentive exists…..e.g compensation, classification and parole..but to be fair we don’t know in NZ.  Not sure of the numbers in the opposite direction where incentive exists..e.g denial, symptom minimisation.Donders and Boonstra, 2007, Green, Rohling, Lees-Haley & Allen 2001; Binder andRohling, 1996; Lees-Haley, 1992; Trueblood & Schmidt, 1993:
    7. 7. What does the psych board say? The psychologist should be alert to motivational factors which may bias the results in a particular direction. Do we consider these factors? Where there is reason to question effort, symptom validity assessment may be included… Hmm Be careful…they are worried about us talking about Malingering… Do we? While psychologists often want to avoid having this uncomfortable discussion, there is an obligation to feedback the results of the assessment to the client. Do we agree? Draft Guidelines on Use of Psychometric Tests NZ Psychologist Board (Dec 2011)
    8. 8. Psychometric review – tests examine: Psychiatric Symptoms (Rare, Improbable Absurd combinations, Severity, Consistency, and Report Versus Observed). Self Deception Validity Scales on Personality Tests Memory symptoms IQ (VIP) Substance Abuse Somatic Perception Embedded measures across test batteriesBest practice suggests converging test data.
    9. 9. Four Case Studies
    10. 10. Case One: s38 Sexual Offender Psychiatrist says fit to plead and no evidence of intellectual impairment Lawyer says clear ID.Only a psychologist can sort this out
    11. 11. Testing Passed TOMM x2 FSIQ in range of <60 (no difference across subtests) Very good at saying yes. BURT 6.5 year reading age Vineland II across two raters consistent with ID Special schooling, no employment, limited coping skillsIt was the symptom validity test that stood out strongly in court to show this was a valid assessment of functioning.
    12. 12. Case Two: ACC Data Assessment(Risky/ SV testing recommended) PAI: strong negative bias DAPS: strong negative bias VIP / TOMM: valid. MSPQ: four times above cut-off for back pain K10: severe CES-D: v.severe in range where inpatient care should be considered.
    13. 13. Where we got to with some feedback… Some rapport was established by meeting twice. Client agreed with strong negative bias Client agreed with paranoid ideation and pervasive distrust, aggrieved, suspected that others plotting against him. This was the substantive barrier to change. Noted incentives Does meet criteria for PTSD but is difficult to treat. Warrants specialist treatment (Psychiatry, Clin.Psychology)
    14. 14. Case Three: s333 Youth court Youth considered by Social Worker based on previous psychology report to have ID and would likely be placed in Youth ID Service Wanting to know what it would mean if he scored lower vs. higher Knows that offending is serious and persistent enough to lead to district court sentencing.
    15. 15. Prior test results… WAIS IV (previous psych)  Scores spanned from the extremely low range – scaled score of 1 to the average range - scaled score of 10.  Matrix reasoning- which is a robust indicator of overall intelligence that is not impacted by schooling was in the average range;  Client admitted to engaging in previous tests with low effort and that he was considering doing so with me because he considered being found to be low functioning would be useful in his court (incentive);
    16. 16. Case Four: [ACC] PTSD as a consequence of physical injuryReferral: Assessment of the likely pre-injury mental healthcondition and any mental condition (using DSM-IV) that issubsequent to this and can be reliably linked to the coveredphysical injury. This should include close examination ofthe possibility of Post Traumatic Stress Disorder any othercognitive, behavioural or emotional patterns that mightexplain reported findings.
    17. 17. Symptom Validity findings…The pattern detected across psychometric tests, clinicalinterview data and corroborative sources indicated that whileMs Jones did not actively or intentionally feign illness orfalsify symptoms, self-report was unreliable and likely toinclude exaggerated symptoms. Ms Jones’s approach tocognitive testing was reported as inconsistent; that is, therewas evidence of periods of optimum and sub-optimum effort.Structured Inventory of Reported SymptomsMillon Clinical Multiaxial Inventory –IIIValidity Indicator ProfileBehavioural EvidencePersonal MotivatorsObserved Testing Behaviour
    18. 18. Injury Focused Formulation (deleted)
    19. 19. Practice points Be a scientist practitioner and strengthen psychological contribution to forensic environment by openly testing alternative hypotheses and the validity of our conclusions. Learn from the forensic field: Assess patterns across test data, note clinical and behavioural observations, consider incentives and use a range of corroborative sources. Develop rapport and inform clients of the components of the assessment Describe and formulate on response style. Develop this component of your forensic report. Consider the utility of feedback and how best to communicate your results both in terms of developing your formulation and being fair to the client in terms of hearing your findings first from you.

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