Identify Malingering with the T.O.V.A.
It's an ugly word and an ugly situation that no clinician likes to encounter. Here's how to spot malingering with the T.O.V.A.'s exclusive new Symptom Exaggeration Index.
Defined in DSM-IV as "the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives," malingering is of particular concern when working with teenagers and adults seeking medical treatment for Attention Deficit Hyperactivity Disorder (ADHD) due to the risk of transfer or abuse of stimulant medications.
One study found that almost 50% of treatment-seeking college students showed evidence of malingering (Sullivan, May, & Galbally, 2007). A recent article in the popular press confirms that misuse and frank abuse of stimulants may be rampant on college campuses. The New Yorker, April 27, 2009.
None of us wants to view our patients with outright suspicion, yet as professionals we play a critical role as gatekeepers for powerful and potentially dangerous medications. How can a clinician working with teenagers and adults complaining of attention problems ensure that self-reported symptoms are truthful?
Self-report symptom checklists are simply not up to the task. As Sullivan et al. found, "...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."
So what can you do to ensure that you're treating patients who really need help and not supplying your patient's roommate and friends with "the Adderall Advantage"? It's simple: Use the TOVA Exaggeration Index (SEI Worksheet). By identifying subtle (but discriminating) signs of exaggeration found in the T.O.V.A. report, the T.O.V.A. SEI gives you the peace of mind that comes from knowing that you are treating those who truly need your help.
Real attention problems are typically confirmed by low scores on the T.O.V.A. As you might expect, exaggerated symptoms also produce low T.O.V.A. scores, but exaggerators are revealed by a number of subtle, yet discriminating "faking bad" signs. Based on the total number of signs, the T.O.V.A. SEI yields an interpretation that ranges from "No evidence of possible symptom exaggeration" to "Almost certain evidence of symptom exaggeration."
A positive history and symptom checklist, converging evidence of problems, poor performance on the T.O.V.A., and a clean score on the SEI confirm that you are likely "good to go" with treatment, and you can use the T.O.V.A. to determine the most effective treatment. You can download the TOVA Exaggeration Index (SEI Worksheet) and be sure to watch for the T.O.V.A. Symptom Exaggeration Index in a future version of the T.O.V.A. report!
References
Sullivan, B.K., May, K., Galbally, L. (2007). Symptom exaggeration by college students in attention-deficit hyperactivity disorder and learning disorder assessments. Applied Neuropsychology 14(3), 189-207.
Hughes, S.J., Leark, R.A., Henry, G.K., Robertson, E.L., Greenberg, L.M. (2008). Using the Test of Variables of Attention (T.O.V.A.) to detect deliberate poor performance during assessment of attention. Poster presentation at the annual meeting of the American Academy of Clinical Neuropsychology meeting, Boston, MA).