Mandi W. Musso

“Why Is This So Hard?” A Review of Detection of Malingered ADHD in College Students

Objective: The purpose of this article is to review studies that have investigated malingered ADHD in college students and offer recommendations for assessing effort in clinical evaluations of ADHD in college students. Method: This article identified and summarized nineteen peer-reviewed, empirical studies published between 2002 and 2011 that investigated malingered ADHD in college students. Results: Few of the measures examined proved useful for detecting malingered ADHD. Most self-report questionnaires were not sensitive to malingering. While there is some variability in the usefulness of neuropsychological test failure, profiles between malingerers and individuals with ADHD are too similar to confidently detect malingered ADHD. Failure of three or more symptom validity tests proved most useful at detecting malingered ADHD. Conclusion: This review suggests that there is substantial need for measures designed specifically for detecting malingered ADHD simulators are able to produce plausible profiles on most tools used to diagnose ADHD.

Optic nerve sheath diameter and lumbar puncture opening pressure in nontrauma patients suspected of elevated intracranial pressure

OBJECTIVE The purpose of this study was to determine if patients with nontraumatic causes of elevated intracranial pressure (ICP) could be identified by ultrasound measurement of optic nerve sheath diameter (ONSD). It was hypothesized that an ONSD greater than or equal to 5 mm would identify patients with elevated ICP. METHOD This was a prospective observational trial comparing ONSD with ICP measured by opening pressure manometry on lumbar puncture (LP). The cohort consisted of a convenience sample of adult patients presenting to the emergency department, requiring LP. The ONSD measurement was performed before computed tomography and LP. The physician performing the LP was blinded to the result of the ONSD measurement. An opening pressure on manometry of greater than or equal to 20 cm H2O and an ONSD greater than or equal to 5 mm were considered elevated. RESULTS Fifty-one patients were included in our study, 24 (47%) with ICP greater than or equal to 20 cm H2O and 27 (53%) with ICP less than 20 cm H2O. The sensitivity of ONSD greater than or equal to 5 for identifying elevated ICP was 75% (95% confidence interval, 53%-90%) with specificity of 44% (25%-65%). The area under the receiver operator characteristic curve was 0.69 (0.54-0.84), suggesting a relationship between ONSD and ICP. CONCLUSION An ONSD greater than or equal to 5 mm was associated with elevated ICP in nontraumatic causes of elevated ICP. Although a relationship exists, a sensitivity of 75% does not make ONSD measurement an adequate screening examination for elevated ICP in this patient population.

Investigation of the Montreal Cognitive Assessment (MoCA) as a cognitive screener in severe mental illness.

This study examined the Montreal Cognitive Assessment (MoCA) as a neurocognitive screener and its relationship with functional outcomes in a sample of outpatients diagnosed with severe mental illness (SMI). The MoCA, Brief Assessment of Cognition in Schizophrenia (BACS), UCSD Performance-Based Skills Assessment Test-2 (UPSA-2), and Global Assessment of Functioning (GAF) were administered to 28 SMI patients and 18 non-psychiatric controls. Patients obtained significantly lower scores on the MoCA, BACS, UPSA-2, and GAF compared to non-patients. The cutoff score <26 of the MoCA resulted in favorable sensitivity (89%) but lower specificity (61%) in classification of SMI patients. The MoCA was significantly correlated with UPSA scores but not GAF scores, whereas the BACS was not significantly correlated with UPSA or GAF scores. When entered into hierarchical regression analyses, the MoCA accounted for significant variance in UPSA scores above variance accounted for by the BACS. Both the MoCA and the BACS contributed unique variance in GAF scores. Overall, the MoCA demonstrated high sensitivity as a cognitive screener in SMI. Moreover, MoCA scores were related to performance-based measures of functional capacity.

Smartphones in Medicine: Emerging Practices in an Academic Medical Center

Advances in mobile phone technology now provide a myriad of resources to physicians’ fingertips. However, the medical profession continues to struggle with potential for misuse of these devices. There is a need for better understanding of physicians’ uses of smartphones in order to establish guidelines for appropriate and professional behavior. The purpose of the current study was to survey physicians’ and medical students’ practices concerning smartphone use in the healthcare setting. Physicians and medical students were asked to complete anonymous surveys regarding uses of smartphones within the past month in various healthcare settings. Overall, the participants reported distinctly different patterns in the uses they made of their phones in different settings (P < .001), with most individuals engaging in most behaviors while on break but few using their smartphones while with patients or during procedures. It appears that physicians and medical students make decisions about using their smartphones according to some combination of three considerations: degree of relevance to patient care, the appropriateness of the behavior in front of patients, and the issue of how disruptive that behavior may be.

Utility of the Personality Assessment Inventory for Detecting Malingered ADHD in College Students

Objective: The purpose of the current study is to examine the utility of the Personality Assessment Inventory (PAI) for detecting feigned ADHD in college students. Method: A sample of 238 undergraduate students was recruited and asked to simulate ADHD (ADHD simulators) or respond honestly (controls) on the PAI. Archival data (n = 541) from individuals diagnosed with clinical ADHD, no diagnosis, learning disorder, mood/anxiety, comorbid ADHD-mood/anxiety, or suspect effort were used. Results: Few individuals scored above the cutoffs on PAI validity scales. When alternative cutoff scores were examined, cutoffs of ≥77 on the Negative Impression Management (NIM) scale, ≥3 on the Malingering Index (MAL), and ≥1 on the Rogers Discriminant Function (RDF) yielded excellent specificity in all groups and sensitivities of .33, .30, and .20, respectively. Conclusion: Individuals who were asked to simulate ADHD easily manipulate the PAI; however, alternative cutoff scores proposed for PAI validity indices may improve the detection of feigned ADHD symptoms.

A Psychometric Evaluation of the STAI-Y, BDI-II, and PAI Using Single and Multifactorial Models in Young Adults Seeking Psychoeducational Evaluation

A psychometric evaluation on the measurement of self-report anxiety and depression using the Beck Depression Inventory (BDI-II), State Trait Anxiety Inventory, Form-Y (STAI-Y), and the Personality Assessment Inventory (PAI) was performed using a sample of 534 generally young adults seeking psychoeducational evaluation at a university-based clinic. Confirmatory factor analysis was used to evaluate single-factor and multifactorial models (including hierarchical and higher-order models). Fit indices indicated superiority of the hierarchical model where the BDI-II and PAI depression subscales loaded onto a depression factor, the PAI anxiety subscales loaded onto an anxiety factor, and the STAI-Y State and Trait scale scores loaded onto a separate factor that indexed variance associated with both depression and anxiety. Findings are discussed in regards to the construct validity of the BDI-II, STAI-Y, and PAI in young adults seeking psychoeducational evaluation and relations among these measures.

Delusional Parasitosis as a Presenting Feature of HIV Dementia: A Case Study

Delusional parasitosis (DP) is a rare form of somatic delusions where a person believes that he or she is infected with worms, bugs, or other parasites. In the literature, DP has been discussed as a presenting feature of cortical dementias but has not been documented as a presenting feature in subcortical dementias such as HIV-associated dementia. We present a case of a 56-year-old male referred from the dermatology clinic for neuropsychological assessment after presenting with persisting claims that he was infected with “bugs” despite evidence to the contrary. The patient had a history of HIV and substance abuse. The patient was diagnosed with dementia due to HIV disease and psychosis due to dementia (i.e., DP) based on the neuropsychological evaluation. This case report suggests that neuropsychological evaluations may be indicated for patients presenting with DP and risk factors for either cortical or subcortical dementias such as HIV-associated dementia.

Using the NAART to Estimate WRAT-4 Reading Grade Level in a Predominantly African American Sample

Tests of word-reading ability, such as the North American Adult Reading Test (NAART) and Wide Range Achievement Test (WRAT) Word Reading subtest, are often used by neuropsychologists to estimate premorbid intelligence. However, despite the fundamental basis in reading, little work has been done to calculate or estimate literacy level from NAART performance. Additionally, few prior studies have evaluated the use of word-reading tests in underrepresented populations such as African Americans or individuals with lower socioeconomic status and educational attainment. Finally, while the correlations between the NAART and older editions of the WRAT are known, no study has yet examined the relationship between the NAART and WRAT-Fourth Edition (WRAT-4). The purpose of the current study, then, was to replicate and extend prior research in these areas. NAART and WRAT-4 Word Reading (WRAT4WR) performances were examined in a sample of 173 primarily African American individuals who were HIV-positive and who had an average of fewer than 12 years of education. Analyses revealed a strong correlation between NAART error scores and WRAT4WR raw scores (r = −.866, p < .001). Linear regression was used to establish the predictive equation to estimate WRAT4WR scores from NAART errors. This information allows for determining reading grade-level equivalents based on NAART error scores.

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.

Factor structure and clinical correlates of the 61-item Wender Utah Rating Scale (WURS)

The objective of this study was to assess the factor structure and clinical correlates of a 61-item version of the Wender Utah Rating Scale (WURS), a self-report retrospective measure of childhood problems, experiences, and behavior used in ADHD assessment. Given the currently mostly widely used form of the WURS was derived via a criterion-keyed approach, the study aimed to use latent variable modeling of the 61-item WURS to potentially identify more and more homogeneous set of items reflecting current conceptualizations of ADHD symptoms. Exploratory structural equation modeling was used to generate factor scores which were then correlated with neuropsychological measures of intelligence and executive attention as well as a broad measure of personality and emotional functioning. Support for a modified five-factor model was found: ADHD, disruptive mood and behavior, negative affectivity, social confidence, and academic problems. The ADHD factor differed somewhat from the traditional 25-item WURS short form largely through weaker associations with several measures of personality and psychopathology. This study identified a factor more aligned with DSM-5 conceptualization of ADHD as well as measures of other types of childhood characteristics and symptoms which may prove useful for both research and clinical practice.