Re-Examination of the Rey Word Recognition Test

The Rey Word Recognition Test, a brief and simple to administer free-standing neurocognitive performance validity test, was examined in a large known-groups sample (122 credible patients and 134 non-credible patients). Total correctly recognized was the most sensitive score, identifying 54% of non-credible participants using a cut-off of ≤6, while maintaining specificity of approximately 90%. However, specifically rates were somewhat lower in credible individuals with <12 years of education or borderline intelligence, or who were bilingual (spoke English as a second language, or learned English concurrently with another language), indicating that cut-offs may require minor adjustment in these groups. Sensitivity rates were much higher in non-credible female versus male mild traumatic brain injury patients (mTBI; 68% versus 48% for total correct), suggesting that the Rey Word Recognition Test is particularly effective in identifying performance invalidity in female mTBI compensation seekers.     

Re-Examination of a Rey Auditory Verbal Learning Test/Rey Complex Figure Discriminant Function to Detect Suspect Effort

Bernard (1990), and Bernard, Houston, and Natoli (1993) identified a discriminant function, derived from Rey figure recall score and RAVLT trial 1 and recognition, which discriminated simulators and controls with 77–85% accuracy. However, in the current study, application of the discriminant function to patients with suspect effort, brain injured patients, and controls, revealed excellent sensitivity (95%) but low specificity (33% for patients, 61% for controls). A new discriminant function using the same Rey figure and RAVLT scores, derived from actual patients with documented suspect effort and patients with confirmed brain injury, resulted in an overall classification of 85% correct, with only 16% of suspect effort and 15% of brain injured patients misidentified. Use of a discriminant function score of = -.40 resulted in sensitivity of 71% while maintaining specificity of =91%.     

The utility of the Rey Word Recognition Test in the detection of suspect effort

The Rey Word Recognition Test potentially represents an underutilized tool for clinicians to use in the detection of suspect effort. The present study examined the predictive accuracy of the test by examining the performance of three groups of participants: (a) 92 noncredible patients (as determined by failed psychometric and behavioral criteria and external motive to feign), (b) 51 general clinical patients with no motive to feign, and (c) 31 learning disabled college students. Results demonstrated gender differences in performance that necessitated separate cutoff scores for men and women. Use of a cutoff score of < or = 7 words correctly recognized identified 80.5% of noncredible female patients while maintaining specificity of > 90%. However, to achieve this level of specificity in male noncredible patients, the cutoff score had to be lowered to < or = 5, with resultant sensitivity of only 62.7%. A combination variable (recognition correct minus false positive errors + number of words recognized from the first 8 words) showed enhanced sensitivity in identifying suspect effort in a subset of the noncredible sample who were claiming cognitive symptoms secondary to traumatic brain injury (i.e., cutoff score of < or = 9 = 81.6% sensitivity with 90% specificity). Results indicate that the Rey Word Recognition Test is an accurate and cost-effective method for the detection of noncredible cognitive performance.     

Effectiveness of the Rey-Osterrieth Complex Figure Test and the Meyers and Meyers Recognition Trial in the Detection of Suspect Effort

The Rey-Osterrieth Complex Figure Test (ROCFT) is a popular measure of visuoconstructive skills and visual memory. A recognition memory trial was recently developed by Meyers and Meyers (1995) and attached to the standard administration of the ROCFT. The addition of this recognition paradigm (comprised of 12 small designs from the original ROCFT stimulus interspersed among 12 foils) makes ROCFT a potentially useful instrument in capturing suspect effort because patients attempting to feign memory difficulties typically operate from the misconception that recognition memory is as impaired as free recall in brain injury and, as a result, suppress recognition performance. The ROCFT (copy, immediate recall [i.e., 3-min recall], and the recognition trial) was administered to four sets of participants: 58 patients with suspect effort; 23 neuropsychology clinic patients with verbal memory impairment, 17 clinic patients with visual memory impairment, and 30 clinic patients without memory impairment. Group comparisons revealed significant group differences in direct copy, immediate recall, and recognition scores of the ROCFT (p &lt;.0001), with the suspect effort group displaying significantly lower performance on the copy and immediate recall scores than the verbal memory impaired and nonmemory impaired clinic patient groups, and significantly lower recognition scores than all three clinical groups. Furthermore, qualitative examination of the recognition trial revealed the presence of “atypical recognition errors” that were endorsed with significantly higher frequency by the suspect effort patients. A combination score incorporating the copy, true positive recognition, and atypical recognition error scores yielded a sensitivity of 74% while misclassifying only approximately 4% of verbal memory impaired clinic patients, 12% of visual memory impaired clinic patients, and 3% of nonmemory impaired clinic patients. Thus, the ROCFT + recognition trial show considerable potential for detecting noncredible effort.     

Validation Of The Sentence Repetition Test As A Measure Of Suspect Effort

It has been suggested that the Sentence Repetition Test (SRT) could serve as an adequate embedded symptom valid ity measure identifying suspect effort during neuropsychological testing. However, very little research has examined sensitivity and specificity rates when using this measure in a variety of clinical settings. The SRT was administered to 1031 patients referred for neuropsychological assessment in outpatient, inpatient, and independent medical evaluation settings. These patients were diagnosed with a wide range of psychiatric, developmental, and neurological disorders. The results of this study reveal that the SRT is a valid measure of suspect effort for the vast majority of these patients (sensitivity = 56.8% and specificity = 95.8% in combined clinical settings). However, analyses also indicate that the SRT is not a valid effort measure for individuals with mental retardation or dementia due to specificity rates falling well below 90% for both groups. Furthermore, the validity of the SRT as an effort measure is questionable for individuals with English as a second language, with a verbal learning disability, with a left cerebrovascular accident, or with an expressive-receptive language disorder due to small sample sizes or borderline specificity rates. Sensitivity, specificity, positive predictive accuracy, and negative predictive accuracy rates are provided for varying cutoff scores in inpatient, outpatient, and IME settings. The results of this extensive study confirm that the SRT can be a useful measure in detecting suspect effort in neuropsychological testing while also providing valuable clinical information.     

Classification Accuracy of Multiple Visual Spatial Measures in the Detection of Suspect Effort

A wide variety of cognitive measures, particularly memory measures, have been studied for their ability to detect suspect effort, or biased responding on neuropsychological assessment instruments. However, visual spatial measures have received less attention. The purpose of this study was to evaluate the classification accuracy of several commonly used visual spatial measures, including the Judgment of Line Orientation Test, the Benton Facial Recognition Test, the Hooper Visual Organization Test, and the Rey Complex Figure Test-Copy and Recognition trials. Participants included 491 consecutive referrals who participated in a comprehensive neuropsychological assessment and met study criteria. Participants were divided into two groups identified as either unbiased responding (UR, N?=?415) or biased responding (BR, N?=?30) based on their performance on two measures of effort. The remaining participants (N?=?46) had discrepant performance on the symptom validity measures and were excluded from further analysis. The groups differed significantly on all measures. Additionally, receiver operating characteristic (ROC) analysis indicated all of the measures had acceptable classification accuracy, but a measure combining scores from all of the measures had excellent classification accuracy. Results indicated that various cut-off scores on the measures could be used depending on the context of the evaluation. Suggested cut-off scores for the measures had sensitivity levels of approximately 32–46%, when specificity was at least 87%. When combined, the measures suggested cut-off scores had sensitivity increase to 57% while maintaining the same level of specificity (87%). The results were discussed in the context of research advocating the use of multiple measures of effort.     

Sensitivity and Specificity of Various Digit Span Scores in the Detection of Suspect Effort

ABSTRACT

Digit Span Age-Corrected Scaled Score (ACSS) and Reliable Digit Span (RDS) have been suggested as effective in assessing credibility. The purpose of this study was to confirm the efficacy of suggested cutoffs for ACSS and RDS and to explore the utility of other Digit Span variables in a large sample (N = 66) of “real-world” ≥ suspect effort patients versus clinic patients with no motive to feign (N = 56) and controls (N = 32). With specificity at ≥ 90%, sensitivity of ACSS increased from 32% to 42% when a ≤ 5 cutoff was used instead of the recommended ≤ 4. The RDS recommended cutoff of ≤ 7 resulted in a sensitivity of 62% but with an unacceptably high false positive rate (23%); dropping the cutoff to ≤ 6 raised the specificity to 93% but sensitivity fell to 45%. Cutoffs for other Digit Span scores did not exceed 45% sensitivity with the exception of 50% sensitivity (11% false positive rate) for average time per digit for all attempted items > 1.0 second. A criterion of ACSS ≤ 5 or RDS ≤ 6 was associated with 51% sensitivity (91% specificity) while RDS ≤ 6 or longest string with at least one item correct ≤ 4 was associated with 54% sensitivity (88% specificity). While only moderately sensitive, Digit Span scores, including new time variables, may have a unique and effective role in the detection of suspect effort.     

The Rey 15-Item Recognition Trial: A Technique to Enhance Sensitivity of the Rey 15-Item Memorization Test

Numerous publications on the Rey 15-item Memorization Test have cited limitations primarily in test sensitivity, as well as to some extent in specificity. In the current study, 49 patients with suspect effort, 36 neuropsychology clinic patients not in litigation or attempting to secure disability, 33 learning disabled college students, and 60 normal controls were administered the Rey Test in standard format followed by a recognition trial. A free recall score &lt;9 was found to have excellent specificity (97–100%), although sensitivity was modest (47%). However, use of a combined recall and recognition score (i.e., free recall+[recognition–false positives] &lt;20) substantially increased sensitivity (71%) while maintaining high specificity (=92%).     

Relationships Between Eight Measures of Suspect Effort

Previous studies have recommended that multiple measures be employed concurrently to provide converging evidence regarding the presence of suspect effort during neuropsychological assessment. However, if the tests are highly correlated they do not represent independent sources of information. To date, no study has examined correspondence between effort tests. The present study assessed the relationships between eight measures which can be used to assess effort (Rey 15-item, Rey Dot Counting Test, Rey Word Recognition Test, RAVLT recognition trial, Rey-Osterrieth Complex Figure Test effort equation, Digit Span, Warrington Recognition Memory Test-Words, and “b” Test) in a sample of 105 patients in litigation or attempting to obtain/maintain disability compensation and who displayed noncredible symptoms based on psychometric performance and behavioral criteria. Modest to moderate correlations were observed between test summary scores with only two measures sharing more than 50% score variance (Digit Span and Dot Counting). Moderate correlations were also observed between individual test scores reflecting indices of response time, free recall, recognition, and false positive errors, providing possible evidence that patients may use specific strategies when producing noncredible performances. Overall the results suggest that the use of these various tests generally provides nonredundant data regarding patient credibility in neuropsychological evaluations.     

The Word Reading Test of Effort in Adult Learning Disability: A Simulation Study

The Word Reading Test (WRT) was designed to detect effort problems specific to a learning disability sample. The WRT and the Word Memory Test (WMT) were administered to two simulator and normal control groups. The WRT showed excellent receiver operating characteristics (e.g., 90% sensitivity and 100% positive predictive power) and outperformed the WMT in detecting both reading and mental speed simulators. This finding and a double dissociation between reading and speed simulators on WRT errors and reaction time suggested specific effort effects while poor effort of simulators on the WMT suggested general effort effects. Results are supportive of the WRT as a potential effort indicator in learning disability.     

Failure to Inhibit the Reading Response on the Stroop Test: A Pathognomonic Indicator of Suspect Effort

We present 6 patients who displayed noncredible effort on neuropsychological testing (verified by failures on specialized measures designed to discreetly assess effort status and multiple behavioral inconsistencies) and complained of complete illiteracy secondary to impoverished educational history, learning disability, or acquired brain injury. The Stroop Test, a measure of a specific aspect of executive function requiring inhibition of an automatized oral reading response in favor of a less habitual, competing color-naming response, was administered to these patients. All six subjects claimed that they were unable to perform the Word-Reading trial as a consequence of total reading disability, but on the Color-Word Interference trial, they all committed “errors” by reading the written words. Five of the six subjects also performed substantially slower on the Interference condition relative to the Color-Naming trial, indicating that they were in fact inhibiting a reading response. However, in cases involving complaints of complete reading illiteracy, the observation of these individuals performing an act that they claimed to be unable to do was the most powerful and pathognomonic indicator of deliberate feigning or exaggeration of impairment in these cases.     

The Rey 15-Item Memory Test and Spanish-Speaking Older Adults

The Rey 15-Item Memory Test (Rey-15) is a standard instrument frequently employed to assess suspect effort/motivation in English-speaking populations. The objective of the current study was to examine the influence of socio-demographic variables on this measure and provide normative data for use with Spanish speakers. The performance of 130 primarily Spanish-speaking, cognitively intact, older adults (ages 50–69) on six Rey-15 scoring systems and six embedded measures of suboptimal performance was examined. Approximately 8% of the sample scored below the recommended cut-off of 9 on the Rey-15. The lowest recall score of 6 was also the minimum score obtained on the recognition trial. Additionally, scores on the alternative Rey-15 scoring methods and the embedded measures of suboptimal performance were lower in comparison to the normative data presently utilized with English speakers, yet comparable across the examined measures. Basic mental status and education level were significant predictors of Rey-15 performance; however, results indicate that these variables may share a close relationship with socio-demographic characteristics such as acculturation level and years of U.S. residency. Preliminary normative data on the Rey-15 for primarily Spanish-speaking older adults, stratified by education, is provided in conjunction with a recommendation for the use of the recognition trial when interpreting results.     

The power of timing: Adding a time-to-completion cutoff to the Word Choice Test and Recognition Memory Test improves classification accuracy

Introduction: The Recognition Memory Test (RMT) and Word Choice Test (WCT) are structurally similar, but psychometrically different. Previous research demonstrated that adding a time-to-completion cutoff improved the classification accuracy of the RMT. However, the contribution of WCT time-cutoffs to improve the detection of invalid responding has not been investigated. The present study was designed to evaluate the classification accuracy of time-to-completion on the WCT compared to the accuracy score and the RMT. Method: Both tests were administered to 202 adults (M_age = 45.3 years, SD = 16.8; 54.5% female) clinically referred for neuropsychological assessment in counterbalanced order as part of a larger battery of cognitive tests. Results: Participants obtained lower and more variable scores on the RMT (M = 44.1, SD = 7.6) than on the WCT (M = 46.9, SD = 5.7). Similarly, they took longer to complete the recognition trial on the RMT (M = 157.2 s,SD = 71.8) than the WCT (M = 137.2 s, SD = 75.7). The optimal cutoff on the RMT (≤43) produced .60 sensitivity at .87 specificity. The optimal cutoff on the WCT (≤47) produced .57 sensitivity at .87 specificity. Time-cutoffs produced comparable classification accuracies for both RMT (≥192 s; .48 sensitivity at .88 specificity) and WCT (≥171 s; .49 sensitivity at .91 specificity). They also identified an additional 6–10% of the invalid profiles missed by accuracy score cutoffs, while maintaining good specificity (.93–.95). Functional equivalence was reached at accuracy scores ≤43 (RMT) and ≤47 (WCT) or time-to-completion ≥192 s (RMT) and ≥171 s (WCT). Conclusions: Time-to-completion cutoffs are valuable additions to both tests. They can function as independent validity indicators or enhance the sensitivity of accuracy scores without requiring additional measures or extending standard administration time.     

The Relationship of IQ to Effort Test Performance

The relationship between IQ and nine effort indicators was examined in a sample of 189 neuropsychology clinic outpatients who were not in litigation or attempting to obtain disability. Participants with the lowest IQ (50–59) failed approximately 60% of the effort tests, while patients with an IQ of 60 to 69 failed 44% of effort indicators, and individuals with borderline IQ (70 to 79) exhibited a 17% failure rate. All patients with IQ < 70 failed at least one effort test. Cutoffs for the Warrington Recognition Memory Test (Words) and Finger Tapping maintained the highest specificities in low IQ samples.     

The Word Accentuation Test - Chicago

A reading test for Spanish speakers in the United States was developed called the Word Accentuation Test-Chicago. The construction and validation of this 40 item test was modeled after reading tests developed in Spain and Argentina, and is based on irregular accentuation of words. The Word Accentuation Test-Chicago was validated on 45 community participants using the Wechsler Adult Intelligence Scale-III in Spanish. Better reading performance was associated with higher intelligence test performance, with an additional 5% of the variation in intelligence score accounted for by reading performance after controlling for age and education. These results indicate that the Word Accentuation Test-Chicago is a psychometrically sound measure of Spanish reading ability that is robustly related to general cognitive ability.     

Comparability of the Rey and Mack Forms of the Complex Figure Test

Equivalent versions of the Complex Figure Test (CFT) are useful for assessing change over time in constructional skills, planning, spatial organization, and visual-spatial memory while minimizing practice effects. To address the need for an equivalent version of the CFT to the Rey, the present study compared copy and 45min-delayed recall accuracy scores of the Rey and Mack CFTs obtained from 245 adults involved in a study of the neuropsychological correlates of sleep apnea and its treatment. Accuracy scores did not significantly differ between individuals with and without sleep apnea. Also, there was no significant difference between copy or recall accuracy scores obtained on the Rey and Mack CFTs. Similar correlations were found between relevant demographic factors, estimated IQ, and accuracy scores for both CFTs. These data suggest that the Mack figure may be a useful alternative to the Rey CFT.     

Alternate form reliability and equivalency of the Rey Auditory Verbal Learning Test

Assessed alternate form reliability and equivalency for the Rey Auditory Verbal Learning Test (AVLT) in a clinical sample. A test-retest, counterbalanced design was utilized with a diagnostically heterogenous group of 85 VA Medical Center patients. The mean test-retest interval was 140 min. Alternate form reliability coefficients were highly significant, all p less than .001, and ranged from .60 to .77. The forms yielded comparable means with differences of less than 1 point on each of the five learning trails and the postinterference (VI) and recognition trials. Total words recalled on trials I through V differed by less than 3 points across forms. From a statistical point of view, when the alternate form was administered second it was slightly more difficult than the original. In the reverse order, the two measures were comparable. Overall, differences between forms lacked clinical significance and the tests were judged to be equivalent measures.     

The Memory Assessment Scales in the Detection of Incomplete Effort in Mild Head Injury

Despite differences in the constructs measured, the Memory Assessment Scales (MAS) remain an alternative to the Wechsler Memory Scales (WMS) as a broad-band instrument for assessing multiple aspects of attention and memory. Although a number of studies have examined indices of the WMS as indicators of malingering, few studies have similarly investigated the MAS. In this study, we examined the degree to which the MAS was effective in detecting incomplete effort in a clinical sample of patients referred for neuropsychological evaluation after mild head injury. Included in the sample were 21 financially compensable (FC) participants with alleged mild head injury and 21 participants who were not involved in litigation and suffered more serious head injuries. Examination of the four MAS domain indices indicated that Short-Term Memory was most useful at identifying incomplete effort. We also examined subscales of the MAS. Consistent with previous findings, brief tests such as Verbal and Visual Span had high rates of diagnostic sensitivity and specificity. Although tests based on a forced-choice recognition paradigm (e.g., Immediate and Delayed Visual Recognition) predicted group membership above chance levels, they failed to significantly add to prediction above Verbal and Visual Span subtests.     

Reliability and validity of the Rey Visual Design Learning Test in primary school children

The Rey Visual Design Learning Test (Rey, 1964, in Spreen & Strauss, 1991) assesses immediate memory span, new learning and recognition for non-verbal material. Three studies are presented that focused on the reliability and validity of the RVDLT in primary school children. Test-retest reliability and the reliability of the scoring protocol proved satisfactory. A verbalization strategy training improved test performance, which indicates that test items are sensitive to verbalization. Further research, especially with clinical samples, is needed to assess its validity and more normative data needs to be gathered. Suggestions for improvements in the test administration are discussed. It is concluded that the RVDLT is a potentially useful instrument to measure different aspects of visual memory in children.