Lecture 11 - Forensic Testing (DN) Flashcards Preview

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Flashcards in Lecture 11 - Forensic Testing (DN) Deck (49):

What is required of the forensic Neuropsychologist?

  • must demonstrate a causative link between
    • cognitive impairment & the event in question


What kind of Battery should be used in a Forensic setting?

  • A fixed battery
  • ensures replicability
  • observations can be backed up


Where did the Daubert standard come from?

  • Daubert was suing a pharmaceutical company
    • believed medication mother took during pregnancy caused cognitive deficits
    • supported by animal studies
  • problem was they couldn't support with human studies
  • led to strict guidelines for forensic assessment


What is the Daubert standard:

Standards expected for forensic testing; resulting from outcome of Daubert case.

Validity of methods are judged by

  • the experts methodology must be testable
  • the technique should not rely on subjective interpretation by the expert
  • the theory must have been peer reviewed
  • the underlying theory or technique should be generally accepted by relevant scientific community
  • the techniques potential rate of error should be low
  • non judicial uses of the theory or technique are also considered


What is the "Motion to Exclude" controversy?

  • Various batteries, including flexible batteries do meet legal requirements if administered & interpreted properly
  • the HRB is very widely used & papers published have been used by defense attorneys to exclude other approaches
  • In reality - the HRB is not the only valid battery, but scientific papers are often used to imply this
  • in particular it is often used to discredit flexible approaches


What special considerations should be made in a Forensic Neuropsychological Assessment?

  • Interview Approach
  • General Assessment Approach: Selection and Administration of  Instruments
  • Estimation of Premorbid Functioning
  • Detection of Malingering
  • Ecological Validity (apply to real life impact)


What are the goals of a forensic interview?

  • establishing causal link between deficit & legal consideration (not documenting deficit)
    • e.g., Rodney King case (riots - sued for police brutality, could not prove causality)
  • focus on inconsistencies
    • aided by multiple sessions
  • focus on dynamic evolution of symptoms
  • discard alternative accounts
  • confirm reported symptoms align with impact on everyday activities



How does a forensic psychologist establish premorbid functioning?

premorbid functioning must be reported in forensic settings

forensic neuropsychologists utilise:

  • Records: School, Military
  • History and Collateral Interview
  • Resistant (crystalised) skills
    • reading, writing, vocabulary, attention for familiar scenes or pictures
  • Demographic variables
    • e.g., rural vs city, education
  • Resistant*Demographic
    • combining resistant & demographic info
  • “Best performance”
  • Include personality assessment


How could a Forensic Neuropsychologist estimate premorbid IQ?

  • no 100% reliable methods
  • combine methods
  • use proxi's of IQ
    • access records (school etc)
    • work position etc
    • collateral interviews
    • reading ability is also good indicator of IQ
  • all combined should provide a good picture of premorbid IQ


What psychometric properties should be considered when selecting instruments in forensic settings?

  • Norms
  • Sensitivity
    • accuracy to detect (signs of) existing conditions
      • detect malingering
  • Specificity
    • accuracy to discard (signs of) non-existing conditions
      • do not want to falsely classify a malingerer if they are not


14:40 & 45:00


What is involved in the administration of instruments in forensic settings?

  • multiple sessions (schedule in advance)
  • rapport
  • record exact dates, times, rapport, sequence of instrument administration
  • stick to standard test instructions
  • clearly record test outcomes, timings in timed tests


What is malingering?

  • Intentional production of false or greatly exaggerated symptoms
  • to attain some identifiable external reward

(Iverson & Binder, 2000)



According to the DSM-IV-TR, what are some symptoms often presented by a malingerer?

  • Physical symptoms (e.g., low back pain)
  • Psychological symptoms (e.g., psychotic)
  • Neurocognitive problems (e.g., poor memory)


What is a very important early step in forensic evaluations?

  • Clarify the referral question
  • be aware of external gains
  • frame referral


What should be present before diagnosing Definite Malingered Neurocognitive Dysfunction (MND)?

  • Presence of a substantial external incentive
  • Definite negative response bias
  • the Negative response bias cannot be otherwise accounted for


What two criteria are used when performing a differential diagnosis of malingering in forensic settings?

  • Control over Behaviour
  • External Reward



What should be present before diagnosing Probable Malingered Neurocognitive Dysfunction (MND)?

  • Presence of a substantial external incentive plus
  • > 2 types of NP evidence (not including negative response bias)


  • 1 type of NP evidence plus 1 type of evidence from self-report
  • Behaviors cannot be otherwise accounted for


What are three Malingering Assessment Methods?

  • Specific tests
    • appear to be testing something else, but actually designed to detect malingering
    • material is well protected - to minimise cheating on these tests
  • Pattern analysis of standard tests
    • does pattern of performance align with symptoms 
  • Detection of inconsistencies



What type of inconsistencies does a forensic psychologist seek to detect?


  • Within reported symptoms (different moments)
  • Between reported and recorded history
  • Between reported symptoms and actual behaviour
  • Between reported symptoms and collateral information
  • Between reported symptoms and performance on tests
  • Between expected scores (considering type and severity of dysfunction) and actual scores
  • Between tests scores and behavioural observations or everyday activities
  • Between tests scores and collateral reports
  • Between neuropsychological domains
  • Between repeated testings



  • What are some forms of Standard Test Pattern Analysis?

  • Easy vs. Difficult Items
  • Indices measuring similar domains
  • Attention vs. Memory
  • Recency and Primacy effects
  • Free recall vs. Recognition
  • Implicit Memory tests


What are some 'fair' reasons that people may try to exaggerate or underperform on an assessment?

  • Assessment conditions
    • Inadequate assessment conditions, poor rapport
      • prison, refugee, cultural, communication difficulties
    • Inadequate tests – culture, language
  • Trait characteristics
    • Cognitive distortions
    • Somatisation, Hypochondriasis
    • Conversion Disorder
  • Condition/Litiation specific states (e.g., may go on for years)
    • Stress, Pain
    • Bad sleep, Fatigue
  • Medication, drug use



How could these 'fair' exaggerations be handles without labelling the peron a malingerer?


  • Ensure “fair” assessment conditions
  • Analyse Records, History (e.g., “hospital records”, “family history – somatisation”)
    • to look at impact on client presentation
  • Diagnostic Tools
  • Trait/State self-reports: Mood, Stress, Sleep, Fatigue
  • Biomarkers
    • e.g., in drug use, check if drug in blood



What should a forensic neuropsychologist considered if Drug Use is suspected to be contributing to an over exaggeration of symptoms? 

  • Patterns of use
  • Severity of dependence
  • Withdrawal
  • Craving
  • Drug testing
  • Saliva
  • Urine
  • Hair


What are some other disorders (other than malingering) that should be considered when faced with an exaggerating client?

  • Factitious disorder
  • Somatoform disorder
  • Depression
  • Personality Disorders
  • Dissociative Identity Disorder


What is negative response bias?

performance below chance

normally when someone is purposely performing poorly (e.g., in malingering)



What is the Rey test?

  • Rey 15 items
  • a malingering test
  • based on floor effects

- create perception it is difficult, by saying this is a difficult task, but try your best!

- it is actually difficult to get it wrong

sensitivity 49% - not that good - as most malingerers would get more than 9 correct (perhaps because it is a little too obvious that it is a malingering test???)

specificity - good - wouldn't have false positives as most people not trying to malinger would do it right 



What is the main focus of malingering tests?

identify best combination of tests to maximise sensitivity & specificity


What are some features of 'Specific Tests' used to detect Malingering?

  • Based on floor effects (15 items)
  • Based on overlearned skills (Dot Counting)
  • Forced choice recognition (VSVT, TOMM)
    • Victoria Symptom Validity Test (stimuli, then blank screen, then two stimuli - choose)
    • Test of Memory Malingering (booklet - 50 stimuli - present at beginning as most difficult to remember 50 items). - as its forced choice (recognition) is much easier than free recall
  • More complex presentations, multiple domains
  • Forced Choice vs. Simplistic
  • Empirical cutoffs vs. Binomial distribution


Which Tests have sensitivity greater than 85%?


  • Digit Recognition
    • Victoria Symptom Validity Test (VSVT)
  • Visual Recognition
    • Test of Memory Malingering (TOMM)
  • Word Recognition
    • Word Memory Test (WMT)


Which of the Forced Choice Tests have sensitivity between 70 - 84%?


  • Digit Recognition
    • Digit Memory Test (DMT) 
  • Visual Recognition
    • Letter Memory Test
    • 48-Pictures Test



  • The b Test


Which of the Tests have sensitivity between 50-69%?


  • Verbal & Nonverbal Abilities
    • Validity Indicator Profile (VIP)


Which of the Forced Choice Tests have sensitivity less than 49%?


  • Digit Recognition Test
    • Portland Digit Recognition Test (PDRT)
  • Word Recognition Test
    • 21-item Test



  • Rey 15-item Test
  • Dot Counting Test


Specificity >85%


  • Digit Recognition
    • Digit Memory Test (DMT)
    • Portland Digit Recognition Test (PDRT)
    • Victoria Symptom Validity Test (VSVT)
  • Visual Recognition
    • Test of Memory Malingering (TOMM)
    • Letter Memory Test
    • 48-Pictures Test
  • Word Recognition
    • 21-Item Test



  • Rey 15-Item Test


Do current malingering tests fall short on sensitivity & specificity? 

Specificity is optimal in many tests

Sensitivity is not so good

e.g., Rey test has good specifiity and not good sensitivity




What are 'low sensitivity'  tests usually based on?

  • Floor effects
  • overlearned skills


What features do tests with Good Sensitivity and Excellent Specificity usually have?

  • Forced choice recognition
  • More complex presentations,
  • multiple domains


Which two tests have the best numbers for sensitivity and specificity?



Other than sensitivity & specificity; what else should be considered when testing for malingering?

  • the Predictive Value (PV) of the test
  • PV is the capacity of the test to actually decide if the person has or has not the disorder or not
  • While sensitivity & specificity are not impacted by the prevalence of the condition in the population, PV is heavily influenced by base rates (prevalence)
    • e.g., base rates - Neuropsych patients 15% / Criminal case 54%
  • calculations at (1:32:20) on lecture (don't think need to know them though)





What three factors should be most highly considered when selecting a test of malingering?

  • Sensitivity 
  • Specificity
  • Predictive Value


What is another way of checking for malingering?

Pattern analysis of other standard tests

  • Easy vs. Difficult Items
  • Indices measuring similar domains
  • Attention vs. Memory
    • if one is good the other most likely should be good
    • check for consistency
  • Recency and Primacy effects
  • Free recall vs. Recognition
    • if recognition is performed worse than free recall - this would be suspicious
  • Implicit Memory tests
    • normally preserved even in brain dysfunctional population


What indices would be used to detect Malingering using Pattern Analysis in Standard Tests?

Pattern Analysis

  • WAIS: Digit Span
    • Malingerers: Low digit span performance (< 4) (below 4 is unusual)
    • Reliable Digit Span (sum of longest correct span for both trials < 7) (below 7 unusual)
    • Vocabulary–DigitSpan(low digit span while vocabulary is high) (t-scores should be similar)
  • Wechsler Memory Scale
    • Malingerers:Attention/Concentration< General Memory
      • (memory would usually be worse)
    • Opposite pattern to typical head injury
  • Verbal learning (e.g., California Verbal Learning Test)
    • Malingerers: Low recognition (hits & forced-choice)
    • Cutoff scores for recall trials produce variable false-positive rates
  • Word Memory Test
    • Malingerers:Inconsistentresponding,poorinitialrecognition
    • Pattern should reflect severity of impairments
  • Category Test
    • Malingerers:Poor performance on first 2 subtests
  • Wisconsin Card Sorting Task
    • Malingerers: Poor ratios of categories completed compared to
      both perseverative errors and failure to maintain set
    • Non-perseveration errors > Perseveration errors
  • Motor Functioning
    ▪ Malingerers: Suppress motor functioning to extreme levels
    ▪ Motor decline should only be associated with severe brain injury



Why would an individual exaggerate symptoms (via self report)?

  • May not be intentional 
  • May be due to other variables (i.e., depression, pain, stress)
    • e.g., Post-Concussive Syndrome persisting for more than 3 months



How can malingering be detected through standard tests?


  • Some standard tests detect malingering e.g., MMPI-2
    • Malingerers tend to show elevations in clinical scales 1, 2, 3, 7, and 8, 
    • the Fake Bad Scale (FBS),
    • VRIN
    • TRIN
    • the Infrequency-Psychopathology Scale [F(p)].
    • The F Scale and F – K does not appear to be as sensitive, and therefore “valid” profiles may be obtained.
  • Caution should be given to interpreting the clinical scales and F Scale derivatives, as these can be easily influenced by psychiatric comorbidities


How can the ecological validity of a forensic assessment be improved? 

When choosing assessment tools

  • Emphasise Verisimilitude over Veridicality.
    • Verisimilitude - tries to make tests very similar to real life situation (e.g., key search test from last week)
    • Veridicality - more pragmatic (practical) - about doing research on the predictive validity of classical tests
  • Clearly define outcomes
    • define as different levels rather than (yes can work or no can't work)
  • Prioritise memory, executive & motor measures (better prediction domains)
  • Consider test properties & previous evidence
    • up to 51% variance explained (this is where we are at now)



What are important considerations in the administration of the assessment?

  • Establishing Rapport
    • provide best possible conditions for assessment
  • Schedule Multiple Sessions
  • Record dates, times, rapport, sequence of tests
  • Stick to standard test instructions
  • Clearly record test outcomes & timing in tests
    • also record the way the patient is coping etc
    • this minimises risk of subjective 


What are some important considerations when administering tests for malingering?

  • Always first
    • if detect malingering, then rest of tests would be invalid
  • Use multiple tests
  • Adjust predictive value to number of tests
    • try to maximise
  • Consider face value of multiple presentation modalities
    • people will normally try to malinger obvious thing (like memory)
    • other tests like executive function (better disguise the test)



What are some guidelines for interpretation of the tests?

  • Consider ALL sources: History, Observations, Tests, Collaterals info, Clinical Judgment
    • don't jump to conclusions from one tests
  • Avoid subjective signs (observations, complaints)
  • lack of scientific evidence regarding validity
  • If there is evidence of malingering
  • All other NP tests patterns should be considered invalid
  • Always use probabilistic/descriptive language in reports
    • (use diagnostic descriptors fron Slick, Sherman e Iverson, 1999; X% probability of malingering according to X)
    • can't label someone a malingerer
  • Provide extensive referencing for your statements in reports



What are some of the challenges faced when testing for malingering?


  • Inherent complexity of the assessment 
  • Protection of specific tests
  • Coaching from lawyers
  • Replicability



What is the difference between a patient who is 'lying' and one who 'lacks awareness' or is in 'denial'

A patient who is lying has

  • purposeful intention
  • cognitive control
    • very different to awareness or denial
  • can use objective markers of lying
    • e.g., fMri - shows cognitive effort involved in lying