1. ADHD in Adults: Conflict of interest disclosure:
Criteria, Comorbidities, I will be discussing some research that I completed while working
as the Director of Education and Research for The TOV A
and Caveats Company, publisher of the Test of Variables of Attention™
(T.O.V.A.), which I will be talking about later in this presentation.
Steve Hughes, PhD, LP, ABPdN While I view my comments and opinions as expressed to be
Assistant Professor of Pediatrics and Neurology accurate, you should judge the facts and materials for yourself and
Division of Pediatric Clinical Neurosciences
make an independent decision regarding your choice of diagnostic
University of Minnesota Medical School
and related techniques.
Today’s Presentation
! Suitability of DSM-IV-TR criteria for Attention-Deficit/
Hyperactivity Disorder in adults
CRITERIA
! Proposed new DSM-V criteria for ADHD in adults
! Adults ADHD and Comorbidities
! Important considerations in diagnosing ADHD in adults

2. ADHD in DSM-IV-TR
! Predominantly Inattentive Type (314.00)
! Predominantly Hyperactive-Impulsive Type (314.01)
! Combined Type (314.01)
! ADHD Not Otherwise Specified (314.9)
A. Inattentive Symptoms A. Inattentive Symptoms
! Often does not give close attention to details or makes ! Often avoids, dislikes, or doesn't want to do things that
careless mistakes in schoolwork, work, or other activities. take a lot of mental effort for a long period of time (such
! Often has trouble keeping attention on tasks or play as schoolwork or homework).
activities. ! Often loses things needed for tasks and activities (e.g.
! Often does not seem to listen when spoken to directly. toys, school assignments, pencils, books, or tools).
! Often does not follow instructions and fails to finish
! Is often easily distracted.
schoolwork, chores, or duties in the workplace (not due to ! Is often forgetful in daily activities.
oppositional behavior or failure to understand
instructions).
! Often has trouble organizing activities.

3. B. Hyperactive/Impulsive B. Hyperactive/Impulsive
Symptoms Symptoms
! Often fidgets with hands or feet or squirms in seat. ! Often blurts out answers before questions have been
finished.
! Often gets up from seat when inappropriate.
! Often has trouble waiting one’s turn.
! Often runs about or climbs excessively (adolescents or
adults, may be limited to feelings of restlessness). ! Often interrupts or intrudes on others (butts into
conversations or games).
! Often has difficulty playing quietly.
! Is often “on the go” or acts as if “driven by a motor”.
! Often talks excessively.
Additional Criteria Rates of ADHD
! Six or more of A and/or B. ! One of the most common psychiatric disorders in children
and adolescents
! Some symptoms that cause impairment were present before
age 7 years. ! Worldwide prevalence about 5.3 percent
! Some impairment from the symptoms is present in two or ! In US, 7.8 percent of all school-aged children (about 4.4
more settings (e.g. at school/work and at home). million) aged 4 to 17 years diagnosed with ADHD at some
point in their lives (CDC)
! There must be clear evidence of significant impairment in
social, school, or work functioning. ! The disorder affects 4.4 to 5 percent of US adults aged 18 to 44
! The symptoms are not better accounted for by another ! Approximately 9.8 million adults believed to have ADHD
mental disorder (e.g. Mood Disorder, Anxiety Disorder, ! (National Comorbidity Survey Replication; Barkley, Murphy,
Dissociative Disorder, or a Personality Disorder). & Fischer, 2008)

4. Diagnosis can be relatively
straightforward…. Q: What do these all have in common?
• Depression • Language disorder
! Interview
• Oppositional Defiant Disorder • Physical or sexual abuse
! Patient observation • Anxiety disorder • Post-Traumatic Stress Disorder
! Child Behavior Checklist (parent and teacher) • Learning disability • Head injury
• Tourette disorder • Neurological disorder
! Conners Parent and Teacher Rating Scales • Poor social history • Intellectual precocity/
! ADD-H: Comprehensive Teacher Rating Scale (ACTeRS) • Lead poisoning impairment
• Hearing impairment • Dementia
! Vanderbilt Assessment Scales • Family style
• Auditory processing problems
but...
American Academy of Child and Adolescent Psychiatry • Sleep problems • Poor school/job “fit”
A: They are all mistaken for ADHD.
ADHD in Adults?
DSM-IV-TR ADHD was built for
Without careful, comprehensive enough use with children
evaluation, almost anything that sends a
person off the rails can look like “ADHD.”

5. DSM-IV-TR ADHD was built for
use with children
! Rate of ADHD does decline with age
! Decline is evident if using threshold cut-scores from
questionnaires (e.g., 93rd or 98th percentile)
! Evidence suggests normalization in around 50% of
patients followed longitudinally
! Full recovery seen in about 35%
! However, strict application of DSM-IV-TR criteria at
transition to adulthood causes dramatic drop in diagnosis
(up to 74%)
DSM-IV-TR ADHD was built for DSM-IV-TR ADHD was built for
use with children use with children
! DSM-IV-TR criteria were never validated in older ! DSM-IV-TR subtypes have no apparent merit for use in
adolescents and adults adults
! Symptom threshold / wording / conceptualization all ! “Impairment” is often subjective
developed for children ! “Impairment” should not be relative to a high-functioning
! Stipulation of areas of impairment not broad enough for specialized peer group or to IQ
older adolescents and adults
! “Style” ≠ “Impairment”
! No real guidelines for determining “impairment”
! For a variety of reasons, self-report is an unreliable
! Age 7 criterion was wholly unempirical in origin and method to ascertain the presence of symptoms
severely limits use in adolescents adults

6. Additional considerations Additional considerations
! ADHD is a symptom-complex not a disorder ! ADHD is confusing
! Multiple etiologies, treatments and prognoses ! Ability to “hyper focus” is not addressed
! Diagnostic criteria are behavioral and subjective ! “Executive functions” not in description, yet commonly
affected
! “Impairment” is subjectively determined
! Symptoms are situation specific, age-linked, and culture
bound
! Symptoms often become manifested after age 7
! Symptoms are clearly age linked
Rethinking ADHD….
Adjusting DSM-IV-TR
! Diagnostic threshold must be adjusted for age
! Current report of 4 or more symptoms from either list, or
a total of 7 symptoms from the 18 DSM-IV-TR
symptoms:
! Rules out 100% of community control group
! Rules in 87% of ADHD group
! But also rules in 70% of clinical control group!
Barkley (2006)

7. “CPTsville” Proposed DSM-V Adult ADHD
symptoms
! Often easily distracted by extraneous stimuli or irrelevant
thoughts
! Often makes decisions impulsively
! Often has difficulty stopping activities or behavior when
should do so
! Often starts projects or tasks without reading or listening to
directions carefully
! Often has poor followthrough on promises or commitments he
(Also here) or she may make to others
After Barkley (2006) ! Often has trouble doing things in proper sequence
Proposed DSM-V Adult ADHD Possible DSM-V Adult ADHD
symptoms symptoms
! Often drives with excessive speed ! Some impairment present in childhood or adolescence (before
age 16)
! Often has difficulty sustaining attention in tasks or leisure time
activities ! Some impairment present in two or more settings (work,
educational activities, home life, community functioning, social
! Often has trouble organizing tasks and activities relationships)
Barkley, Murphy & Fischer (2008) ! Clear evidence of clinically significant impairment in multiple
areas of functioning
Barkley, Murphy & Fischer (2008)

8. COMORBIDITIES
Comorbidity in children
1216 BIOL PSYCHIATRY 2005;57:1215–1220 Comorbidity in children
J. Biederman
! Almost one-third of children with ADHD have more than
one comorbid condition.
DOHHS, Agency for Healthcare Research and Quality
Figure 2. Approximate prevalence of comorbid diagnoses in adults with
attention-deficit/hyperactivity disorder.
Figure 1. Approximate prevalence of comorbid diagnoses in children with
attention-deficit/hyperactivity disorder. 2004). Lifetime prevalence rates of comorbid anxiety disorders in
adults with ADHD approach 50%, whereas mood disorders,
Biederman J. (2005). Attention-Deficit/hyperactivity disorder: A selective overview. Biolantisocial disorders, and alcohol/drug dependency also show
three domains; 20% did well in all three domains; and 60% had Psychiatry
57, 1215-1220. intermediate outcomes. These findings suggest that the syn- substantial prevalence rates (Figure 2) (Biederman et al 1993,
dromic persistence of ADHD is not associated with a uniform 1994; Shekim et al 1990). Findings from a new, large sample of
functional outcome; rather, it leads to a wide range of emotional, male and female adults with and without ADHD provide com-
educational, and social adjustment outcomes that can be partially pelling evidence for the validity of adult ADHD and document
predicted. More work is needed, however, to disentangle the strikingly similar phenotypic features of the disorder in both
role of treatment on outcome. genders (Biederman et al 2004). Consistent with previous find-
ings, this study documented high rates of mood and anxiety

9. 215–1220 Comorbidity in Adults J. Biederman Q: What do these all have in common?
• Depression • Language disorder
• Oppositional Defiant Disorder • Physical or sexual abuse
• Anxiety disorder • Post-Traumatic Stress Disorder
• Learning disability • Head injury
• Tourette disorder • Neurological disorder
• Poor social history • Intellectual precocity/
• Lead poisoning impairment
• Hearing impairment • Dementia
Figure 2. Approximate prevalence of comorbid diagnoses in adults with
attention-deficit/hyperactivity disorder. • Auditory processing problems • Family style
d diagnoses in children with • Poor school/job “fit”
2004). Lifetime prevalence rates of comorbid anxiety disorders in • Sleep problems
adults with ADHD approach 50%, whereas mood disorders,
Biederman J. (2005). Attention-Deficit/hyperactivity disorder: A selective overview. Biol Psychiatry
domains; and57, 1215-1220. antisocial disorders, and alcohol/drug dependency also show
60% had
suggest that the syn- substantial prevalence rates (Figure 2) (Biederman et al 1993, A: They are all mistaken for ADHD.
ociated with a uniform 1994; Shekim et al 1990). Findings from a new, large sample of
wide range of emotional, male and female adults with and without ADHD provide com-
mes that can be partially pelling evidence for the validity of adult ADHD and document
ver, to disentangle the strikingly similar phenotypic features of the disorder in both
genders (Biederman et al 2004). Consistent with previous find-
Best practice: Multi-method
ings, this study documented high rates of mood and anxiety
disorders in adults with ADHD, with a female predominance.
cal feature observed in
n children, psychiatric
Genetics and ADHD
Familial Influence
assessment approach
de oppositional defiant Family studies of ADHD have consistently supported its
ders (both unipolar and strong familial nature (Faraone and Doyle 2001; Faraone and ! Must consider rule-outs and comorbidities
disorders (Kessler 2004; “The goal1995). Despite nosologic changes, thereis to provide a
Tsuang of a comprehensive evaluation is remarkable
bidity can occur due to
nd Rutter 1991), recent
model oras between early(Cantwell 1972; Morrison and Stewart
agreement
defined
studies of children whose illness was
diagnosis that: (a) accurately characterizes an
hyperactivity
! Must ascertain DSM-IV-TR symptoms of ADHD
artifacts cannot explain individual’s functioning; (b) facilitates thinkingDSM-III-R
1971) and subsequent studies using DSM-III and about the
ty observed for ADHD individual; (c) explains his or (Biederman et al 1990; Faraone
definitions of ADHD (Figure 3) her current difficulties; and
! Should establish a baseline for treatment monitoring
the prevalence rates of et al 1992; Frick et al 1991; Schachar and Wachsmuth 1990). Most
(d) guides effective intervention” (Hughes, 2008).
hood ADHD and how family studies have identified a two- to eightfold increase in the ! Should address ongoing need for treatment
t to gender (Biederman risk for ADHD in parents and siblings of children with ADHD
t al 1999). (Biederman et al 1990; Cantwell 1972; Faraone et al 1992; Frick ! Should include multimodal treatment strategy
pact of gender on the et al 1991; Manshadi et al 1983; Morrison and Stewart 1971; Pauls
al (2002) reported that et al 1983; Schachar and Wachsmuth 1990; Welner et al 1977). A
or comorbid disruptive study of siblings of adults with ADHD (Manshadi et al 1983) and
! May require case coordination
HD. Because disruptive
nding might explain the ! May require reformulation if “model” does not provide
ale ratio between clinic-
mples of children with
predicted outcomes
ore, this gender discrep-
ght be under-identified

10. “Clinicians should consider utilizing several methods of
establishing impairment, such as a combination of patient-reported
history, corroboration through others who know the patient well,
CAVEATS
and archival records that may reflect such impairment, as in
school, medical, mental health, employment, criminal and driving
records” (p. 39-40, Barkley, Murphy & Fischer, 2008).
Under-reporting of symptoms
Malingering

11. ADHD and under-reporting ADHD and under-reporting
! ADHD symptoms may be overlooked in persons being “Patients may also lack insight into their problems and
treated for other psychiatric illness assume that their ADHD symptoms are personality or
! Some patients are hesitant to admit to “poor character” character traits. They may not understand the manner in
which ADHD symptoms appear in an adult. For these and
other reasons, patients may fail to mention ADHD
symptoms to their healthcare provider unless they are
specifically asked” (p. 978, Barkley & Brown, 2008).
A young man I’ll call Alex recently graduated from
Harvard. As a history major, Alex wrote about a dozen
papers a semester. He also ran a student organization,
for which he often worked more than forty hours a
week; when he wasn’t on the job, he had classes.
Weeknights were devoted to all the schoolwork that he
couldn’t finish during the day, and weekend nights
were spent drinking with friends and going to dance
parties. “Trite as it sounds,” he told me, it seemed
important to “maybe appreciate my own youth.” Since,
in essence, this life was impossible, Alex began taking
Adderall to make it possible.
From“Brain Gain: The underground world of
neuroenhancing drugs.” The New Yorker, April 27,
2009.

12. Malingering is a big problem in Malingering is a big problem in
adult ADHD work adult ADHD work
! Adults malinger to obtain: ! Special dispensations
! Medication to sell or trade ! Extended time on exams
! Medication to abuse ! Reduced work load
! Medication for “neuroenhancement”
Malingering is a big problem in
ADHD and Malingering
adult ADHD work
! To win lawsuits
! Rates of symptom exaggeration / malingering may
approach 50% among treatment seeking college
students
! “...clinicians who rely upon self-report measures in the
absence of performance-based symptom validity
measures in ADHD assessment are probably risking far
more false-positives than they suspect” (Sullivan, May,
& Galbally, 2007)

13. Self-report is easily faked
“In analyzing the performance of students simulating
ADHD, and comparing it to performance of both non-
Heilbronner, R.L., Sweet, J.J., Morgan, J.E., Larrabee, G.J., Millis, S.R.
ADHD and genuine ADHD students, this study clearly (2009). American academy of clinical neuropsychology consensus
demonstrated that the symptoms of ADHD are easily conference statement on the neuropsychological assessment of effort,
response bias, and malingering. The Clinical Neuropsychologist, 23,
fabricated, and that simulators would be
1093-1129.
indistinguishable from those with true ADHD” (p. 577,
Harrison, Edwards & Parker, 2007).
Some of the recommendations
The evaluation of self-reported symptoms is best accomplished using
Development of the T.O.V.A.
!
psychometric instruments containing proven validity measures.
! If possible clinicians should use multiple validity measures covering
multiple domains distributed throughout the testing.
Symptom Exaggeration Index
! If testing must be brief (e.g., Social Security disability evaluations),
minimally, embedded effort indicators should be examined.
! Stand-alone effort measures and embedded validity indicators should
both be employed.
Heilbronner, R.L., Sweet, J.J., Morgan, J.E., Larrabee, G.J., Millis, S.R. (2009). American
academy of clinical neuropsychology consensus conference statement on the
neuropsychological assessment of effort, response bias, and malingering. The Clinical
Neuropsychologist, 23, 1093-1129.

14. The Clinical Neuropsychologist, 19: 121–129, 2005
Copyright # Taylor and Francis Ltd.
ISSN: 1385-4046
DOI: 10.1080=13854040490516604
Downloaded By: [University of Minnesota] At: 04:18 3 June 2007
Archives of Clinical Neuropsychology
17 (2002) 335 – 342
PROBABLE MALINGERING AND PERFORMANCE
ON THE TEST OF VARIABLES OF ATTENTION
George K. Henry
Fake bad test response bias effects on the Los Angeles Neuropsychology Group, Los Angeles, CA, USA
test of variables of attention$ Fifty subjects with mild head injury involved in personal injury litigation and 2 subjects
referred for evaluation of their disability status underwent comprehensive neuropsycholo-
Robert A. Leark*, Dennis Dixon, Tiffany Hoffman, Donna Huynh gical examination including the Test of Variables of Attention (TOVA). Group status
was determined by performance on symptom validity testing. Twenty-six subjects who
Psychology Department, Pacific Christian College, 2500 East Nutwood Avenue, failed symptom validity testing formed the probable malingering (PM) group, while 26
Fullerton, CA 92831, USA subjects who passed symptom validity testing comprised the not malingering (NM)
group. Subjects in the PM group performed significantly worse on all TOVA variables
Accepted 5 February 2001 relative to subjects in the NM group. Discriminant function analyses revealed that TOVA
omission errors 3 errors was the best predictor of group status. Malingering research
employing a group of probable clinical malingerers has direct generalizability to real-
world settings.
Abstract
This study investigated the effects of faking bad (FB) on the Test Of Variables of Attention
(TOVA) using subjects randomly placed into two groups. Subjects in Group 1 took the TOVA under INTRODUCTION
normal conditions (NC) first; they were then requested to subtly fake bad. Group 2 subjects took the Neuropsychologists are increasingly being called upon to render expert opi-
TOVA under the same fake bad instructions first, then took the test under normal conditions the nions in the forensic area. The science upon which these opinions are based must
second time. An analysis of the effects of test order yielded non-significant differences for basic meet acceptable standards of reliability and validity. Confidence in the reliability
TOVA variables across all four quarters, both halves and the total score. An analysis for group mean and validity of the test data generated during the neuropsychological evaluation is
differences between the NC and the FB instructions yielded significant differences across the basic directly related to the examinee’s effort. In recent years the development of symp-
TOVA variables across the four quarters, two halves and total score. The FB group had excessive tom validity tests (SVTs) such as the Test of Memory Malingering (TOMM;
amounts of omission and commission errors, a greater response time mean (i.e., slower to respond) Tombaugh, 1996), Word Memory Test (WMT; Green, Allen, Astner, 1996),
and had greater variance around their mean response time. The study affirms that the professional and Computerized Assessment of Response Bias (CARB; Condor, Allen,
using the TOVA needs to carefully eliminate a fake bad test-taking bias when subjects produce Cox, 1992) have emerged on the scene to assist clinicians in objectively measuring
excessive test results. D 2002 National Academy of Neuropsychology. Published by Elsevier one’s effort. There has also been a growing interest in developing effort indices on
Science Ltd. standardized neuropsychological tests in order to provide additional data on
which to base effort opinions (Suhr Boyer, 1999; Mittenberg, Rotholic, Russell,
Keywords: TOVA; Continuous performance test; CPT; Fake bad Heilbronner, 1996; Greiffenstein, Baker, Gola, 1996; Millis, Putnam, Adams,
Ricker, 1995; Mittenberg et al., 2001), but also to control for attorney coaching.
One survey of 70 attorneys (Wetter Corrigan, 1995) found that 79% believed
that a discussion with the client about what psychological testing involves should
take place prior to evaluation, while 47% reported that the attorney should
$
Address correspondence to: George K. Henry, Ph.D.=ABPP-CN, Los Angeles Neuropsychology
Portions of this paper were presented as a poster paper at the 19th Annual Meeting of the National Academy Group, 1950 Sawtelle Blvd., Suite 342, Los Angeles, CA 90025, USA. Tel.: 310 457 0777. Fax: 310 457
of Neuropsychology, San Antonio, TX, November 1999. The TOVA Research Foundation supplied use of the test 0777. E-mail: GHenry0249@aol.com
for this research project. Accepted for publication: April 15, 2004.
* Corresponding author. Tel.: +1-714-879-3901; fax: +1-714-879-1041.
E-mail address: bleark@hiu.edu (R.A. Leark).
121
0887-6177/02/$ – see front matter D 2002 National Academy of Neuropsychology.
PII: S 0 8 8 7 - 6 1 7 7 ( 0 1 ) 0 0 11 8 - 4
Leark et al. (2002) Henry (2005)
! 36 college students counterbalanced “good effort” and ! 52 personal injury litigants
“fake bad” conditions ! 26 Classified as “Probably Malingering”
! Excessive: ! 26 classified“Not Malingering” based on established SVTs
! Commission Errors (raw score = 14 +/- 17) ! PM showed Excessive:
! Omission Errors (raw score = 25 +/- 27) ! Commission Errors (Raw score = 21 +/- 39)
! RT Variability (227 +/- 118 ms) ! Omission Errors (raw score = 54 +/- 72)
! RT Variability (230 +/- 94 ms)

15. Goals for TOVA SEI
! Extend current research
! Leverage accurate RT measurement
! Seek obligatory differences between good effort and “fake
bad”
! Identify subtle vs. obvious “tells”
! Yield probabilistic interpretation based on sum of
multiple indicators
From Henry (2005) ! Differentiate “exaggeration” from frank malingering
Valid TOVA Pattern
Acceptable RT Variability
Evidence of Post-error Slowing
Non-excessive Errors (raw score)

16. Edith Kaplan, PhD
(February 16, 1924 - September 3, 2009)
“Edithʼs Rule”
Commission Error RT should be Correct Response RT
Using the Test of Variables of Attention (T.O.V.A.TM) to Detect Deliberate Poor Performance During Assessment of Attention
Steven J. Hughes1, Robert A. Leark2, George K. Henry3, Ellen L. Robertson4, Lawrence M. Greenberg1
1The TOVA Company, Los Alamitos, CA; 2Pacific Christian College, Fullerton, CA; 3Los Angeles Neuropsychology Group, Los Angeles, CA;
4Flaro and Associates, Edmonton, Alberta
Within subject RT profile
ABSTRACT a cut score of 3 Omission Errors yielded a sensitivity of 88.5% and a established SVTs (WMT MSVT; Green 2003, 2008). Valid RT profiles
specificity of 80.8% in predicting PM versus probably Not Malingering were seen in 11 cases (31%). There was no discernable pattern of SVT
Efforts to exaggerate impairment through intentionally poor (NM; a matched group of individuals who passed symptom validity performance observed between specific T.O.V.A. SV rules and the
performance can adversely affect the results of Continuous tests). results of the SVTs.
Performance Tests (CPTs). Previous research with the T.O.V.A.TM has
identified extreme error scores and high reaction time variability as These studies showed that extreme error rates are useful in identifying DISCUSSION
characteristics of deliberate poor performance (Leark, Dixon, Hoffman persons attempting to exaggerate impairment on the T.O.V.A. However,
Huynh, 2001; Henry, 2005). Further analysis of these data sets with simple coaching, motivated malingerers could easily reduce error Combination of “overt” signs of symptom exaggeration based on
shows that differences in error and post-error reaction times (RTs) can rates to a more “typically impaired” level, thereby reducing their extreme error scores and “subtle” signs based on intra-subject reaction
also distinguish valid T.O.V.A. protocols from those obtained under likelihood of being identified. time differences shows promise as a method to improve detection of
conditions of symptom exaggeration. A preliminary T.O.V.A. symptom deliberate fake bad responding on the T.O.V.A.. Violation of 2 or more
validity (SV) model suggests that deliberately poor performance in Further analyses were performed on available portions of the Leark et T.O.V.A. SV rules was seen in 95% (18 of 19) of the protocols in the
! Reaction time for Commission Errors (CERT) adults can yield: 1) Extreme error scores [Omission and/or Commission
Error Standard Scores 45]; 2) Extreme RT Variability [! 180 ms]; 3)
Commission Error RT ! Correct RT; 4) Post-commission Error RT
al. and Henry data sets to investigate the use of reaction time
differences as an adjunct to extreme errors scores in the formulation of
a strong T.O.V.A. SV model that might prove resistant to coaching.
Leark et al. study’s “fake bad” condition, while none of the “good effort”
protocols showed violation of more than one SV rule. Available data
allowed one RT-based SV rule to be tested in the Henry data set, which
correct RT. T.O.V.A. SV scores did not correlate with performance on showed promise in the use of RT-based SV rules in discriminating
other Symptom Validity Tests (SVTs) in a sample of children and CURRENT ANALYSIS between NM and PM personal injury litigants.
adolescents, suggesting that these rules may not be appropriate for
use with children and adolescents. Because these RT differences The T.O.V.A. is unique among commercially available CPTs in that it Comparisons of T.O.V.A. fake bad scores with performance on SVTs in
! Reaction time for Correct Responses (CRRT) reflect different levels of processing in genuine and deliberately poor
performance, this method of assessing SV may prove highly resistant
to deliberate manipulation.
records subjects Response Times (RTs) with ± 1 millisecond accuracy.
This level of precision allows reliable comparison of subtle reaction time
differences that is not possible with less accurate measures. The
a group of children and adolescents did not show a clear relationship,
suggesting that without motivation for systematic response bias,
younger individuals may demonstrate varying levels of effort across
current analysis examined within-subject differences across tasks. The T.O.V.A. SV rules may help clinicians identify T.O.V.A.
BACKGROUND Commission Error RT (CERT; reflecting impulsive, incorrect protocols that are invalid due to factors such as affective instability,
responding), Correct Responses RT (CRRT; reflecting observation, confusion, or poor motivation in this group.
The T.O.V.A.TM is a computerized CPT that provides information about evaluation, and correct responding to the target stimulus), and Post
! Reaction time for correct responses made after a vigilance, response inhibition, consistency of performance over time,
and adaptation to to changing task demands. It is widely used to
assess attention and inhibition and to monitor response to treatment of
-commission-Error Correct RT (PCERT; reflecting post-error RT slowing;
see Li, Huang, Yan, Paliwal, Constable, Sinha, 2008) in available
portions of the above data sets.
SV rules based on intra-subject CERT, CRRT, and PCERT differences
show strong potential, as these reaction times are associated with
differential levels of cognitive processing. It may be difficult or
commission error (PCRT)
attention problems. impossible for those seeking to feign impairment to produce a valid
In addition to non-extreme error scores and non-extreme RT Variability T.O.V.A. RT profile, and these RT-based SV rules may prove to be quite
Because CPTs have strong face validity as tests of attention, they are scores, it was predicted that valid T.O.V.A. protocols would show intra resistant to coaching.
likely targets for “faking bad” by persons desiring to simulate poor -subject Response Time differences consisting of CERT CRRT, and
attention. Previous research investigating “fake bad” patterns in college PCERT than CRRT. Thus, the reaction time profile for a valid T.O.V.A. Future work will further test this T.O.V.A. SV model in a simulation study
students and persons involved in personal injury litigation emphasized protocol should resemble: and in populations in which individuals may be motivated to simulate
extreme error scores as one method for detecting fake bad attention impairment.
Valid: CERT CRRT PCERT
performance on the T.O.V.A. CERT CRRT PCERT
!
Leark, et al., (2002) administered the T.O.V.A. to 36 college students Invalid T.O.V.A. protocols were expected to show violation of one or Good Effort! Fake Bad!
(age = 22.4 ± 2.3) in counterbalanced “fake bad” and “normal” effort more of these RT relationships, in addition to extreme error scores or (n=19) (n=19)
conditions. In the fake bad condition, extreme scores were noted for RT variability. Showed Full Valid RT Profile 7 (37%) 4 (9%)
Omission Errors (raw score = 25 ± 27), Commission Errors (raw score
= 14 ± 17), and Response Time Variability (raw score = 227 ± 118 ms). College student sample. Raw data files for 19 of Leark et al.’s original Violated CERT ! CRRT Rule 0 (0%) 11 (58%)
Standard scores were not calculable for such extreme values, and are 36 cases were available for additional RT analyses. Comparison of RT Violated CRRT ! PCERT Rule 8 (42%) 8 (42%)
reported as “ 40” in the T.O.V.A. report. profiles and T.O.V.A. SV rules by condition are shown in Table 1. Violated Extreme Errors Rule 1 (5%) 14 (74%)
Violated Variability ( 180 ms) Rule 0 (0%) 14 (74%)
Henry (2005) examined the T.O.V.A. performances of 26 personal injury Personal injury litigants. In available data from the Henry (2005) data
litigants (age = 37.8 ± 10.9) identified as “Probably Malingering” (PM) set, 92% of the NM cases passed the CRRT PCERT rule (23 of 25 Violated 1 rule 4 (21%) 1 (5%)
by their performance on established symptom validity tests (SVTs). cases), while only 43% of the PM cases passed this rule (9 of 15 Violated 2 rules 0 6 (31%)
Similar to the findings of Leark et al., PM cases demonstrated extreme cases). Additional RT SV rules could not be calculated from the data Violated 3 rules 0 10 (53%)
error scores across all T.O.V.A. scores with particularly high rates of available. Violated 4 rules 0 2 (10%)
Omission Errors (raw score = 54 ± 72), Commission Errors (raw score Table1. Intra-subject RT and error rules for Good Effort and Fake Bad
= 21 ± 40), and high Response Time Variability (raw score = 230 ± 94 Children and Adolescents. The four T.O.V.A. SV rules were tested in a conditions in the Leark et al. college student sample.
ms). Standard scores were not calculable for such extreme values and sample of 26 children and adolescents (11 female, 15 male; age = 3.3 ±
are reported as “ 40” in the T.O.V.A. report. Further analysis found that 3.0) who received a neuropsychological evaluation including a series of

17. SVI Interpretation
! 0-1: No evidence of symptom exaggeration.
! 2: Some evidence of possible symptom exaggeration.
! 3: Strong evidence of possible symptom exaggeration.
! 4: Very strong evidence of symptom exaggeration.

19. The Future
! Validate SEI in multiple patient groups
Try to differentiate “subtle” and “obvious” methods of
CONCLUSIONS
!
faking bad
! Produce final post-test probability estimation based on
chained likelihood ratios (e.g., Larrabee, 2007)

20. Conclusions Conclusions
! ADHD assessment is “easy” to diagnose but requires ! Underreporting may also be a concern with some adults.
consideration of comorbidities and rule outs. This cannot ! Self-report is easily and credibly faked to suggest the
all be done with simple diagnostic checklists.
presence of ADHD
! DSM-IV-TR criteria were developed for use with children ! Use of a good objective measure with integrated “fake
and must be adapted for use with adolescents and adults.
bad” detection based on obligatory psychophysiologic
! Conceptualization of ADHD as an impairment of executive signs can be useful in clinical decision making
functions is guiding the development of ADHD in DSM-V. ! The T.O.V.A. and T.O.V.A. SEI can plan an important role
Adult criteria will likely be different for DSM-V.
in general and forensic neuropsychological assessment.
! Malingering is a genuine, very serious concern in work
with adolescents and adults.
Thank you!
sjh@umn.edu
www.GoodAtDoingThings.com
651-895-4802