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VALIDITY ASSESSMENT
IN CLINICAL NEUROPSYCHOLOGICAL PRACTICE
Evidence-Based Practice in Neuropsychology
Kyle Brauer Boone, Series Editor

Clinical Practice of Forensic Neuropsychology:

An Evidence-Based Approach
Kyle Brauer Boone

Psychological Assessment:
A Problem-Solving Approach
Julie A. Suhr

Validity Testing in Child and Adolescent Assessment:

Evaluating Exaggeration, Feigning, and Noncredible Effort
Michael W. Kirkwood, Editor

Neuropsychological Report Writing

Jacobus Donders, Editor

Assessment of Feigned Cognitive Impairment:

A Neuropsychological Perspective, Second Edition
Kyle Brauer Boone, Editor

Validity Assessment in Clinical Neuropsychological Practice:

Evaluating and Managing Noncredible Performance
Ryan W. Schroeder and Phillip K. Martin, Editors
VALIDITY ASSESSMENT IN
CLINICAL NEUROPSYCHOLOGICAL
PRACTICE Evaluating and Managing
Noncredible Performance

edited by
Ryan W. Schroeder
Phillip K. Martin

Series Editor’s Note by Kyle Brauer Boone

THE GUILFORD PRESS

New York  London
Copyright © 2022 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
[Link]

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval system,

or transmitted, in any form or by any means, electronic, mechanical, photocopying,
microfilming, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards of practice that are
accepted at the time of publication. However, in view of the possibility of human error or
changes in behavioral, mental health, or medical sciences, neither the authors, nor the editors
and publisher, nor any other party who has been involved in the preparation or publication
of this work warrants that the information contained herein is in every respect accurate or
complete, and they are not responsible for any errors or omissions or the results obtained from
the use of such information. Readers are encouraged to confirm the information contained in
this book with other sources.

Last digit is print number: 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Names: Schroeder, Ryan W., editor. | Martin, Phillip K., editor.
Title: Validity assessment in clinical neuropsychological practice :
evaluating and managing noncredible performance / edited by Ryan W.
Schroeder, Phillip K. Martin.
Description: New York : The Guilford Press, [2022]
Identifiers: LCCN 2021029610 | ISBN 9781462542499 (hardcover)
Subjects: LCSH: Neuropsychological tests. | Clinical neuropsychology. |
BISAC: PSYCHOLOGY / Neuropsychology | PSYCHOLOGY / Assessment, Testing &
Measurement
Classification: LCC RC386.6.N48 V35 2022 | DDC 616.8/0475—dc23
LC record available at [Link]
About the Editors

Ryan W. Schroeder, PsyD, ABPP-CN, is a board-certified clinical neuropsychologist

practicing both clinical and forensic neuropsychology. He is a tenured Associate Profes-
sor in the Department of Psychiatry and Behavioral Sciences at the University of Kansas
School of Medicine–Wichita, and Adjunct Faculty in the Clinical Psychology Program
at Wichita State University. Dr. Schroeder has published numerous high-impact journal
articles and book chapters on neuropsychological validity assessment, presented on var-
ied validity assessment issues at multiple national conventions, and served on expert com-
mittees related to topics such as validity assessment and test security within neuropsycho-
logical settings. His scholarly work and professional contributions to the field have been
recognized by an Early Career Award from the National Academy of Neuropsychology,
an Early Career Achievement Award from the American Psychological Association, and
Fellow designation from the National Academy of Neuropsychology.

Phillip K. Martin, PhD, ABPP-CN, is a board-certified clinical neuropsychologist and

Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the Uni-
versity of Kansas School of Medicine–Wichita. Dr. Martin is an active clinician, super­
visor of neuropsychology trainees, teacher, and researcher. His published works target
the topics of validity assessment and neuropsychological evaluation of dementia and
movement disorders. He has made unique contributions to the neuropsychological valid-
ity assessment literature with his scholarly articles pertaining to professional beliefs and
practices, the management of clinical patients who produce invalid test performance,
and meta-analysis of specific validity measures. In addition to his published research, Dr.
Martin’s participation in the evolving discussion of neuropsychological validity assess-
ment practice has included serving as an expert committee member and being a recurrent
national conference speaker.

v
Contributors

Kaley Angers, MS, Department of Psychology, Ohio University, Athens, Ohio

Patrick Armistead‑Jehle, PhD, ABPP, Concussion Clinic, Munson Army Health Center,
Fort Leavenworth, Kansas
Bradley N. Axelrod, PhD, ABN, John D. Dingell Department of Veterans Affairs
Medical Center, Detroit, Michigan
K. Chase Bailey, PhD, ABPP, Department of Psychiatry, UT Southwestern Medical Center,
Dallas, Texas
Yossef S. Ben‑Porath, PhD, ABPP, Department of Psychological Sciences, Kent State University,
Kent, Ohio
Kyle Brauer Boone, PhD, ABPP, Department of Psychiatry, University of California, Los Angeles,
Los Angeles, California, and private practice, Torrance, California
Shane S. Bush, PhD, ABPP, Department of Psychology, University of Alabama,
Tuscaloosa, Alabama, and Long Island Neuropsychology, P.C., Lake Ronkonkoma, New York
Carolyn T. Caldwell, PhD, Neuropsychology Department, Kennedy Krieger Institute,
Baltimore, Maryland
Michael Chafetz, PhD, ABPP, Algiers Neurobehavioral Resource, New Orleans, Louisiana
Brechje Dandachi‑FitzGerald, PhD, Department of Clinical Psychology Science,
Maastricht University, Maastricht, The Netherlands, and Mondriaan Mental Health Institution,
Heerlen, The Netherlands
Jeremy J. Davis, PsyD, ABPP, Department of Neurology, University of Texas Health Science
Center at San Antonio, and The Glenn Biggs Institute for Alzheimer’s and Neurodegenerative
Diseases, San Antonio, Texas
John H. Denning, PhD, Mental Health Service Line, Ralph H. Johnson Veterans Affairs
Medical Center, and Department of Psychiatry and Behavioral Sciences, Medical University
of South Carolina, Charleston, South Carolina
Christopher J. Graver, PhD, ABPP, Department of Neuropsychology, Madigan Army
Medical Center, Tacoma, Washington

vii
viii Contributors

Jordan T. Hall, MA, Department of Psychological Sciences, Kent State University, Kent, Ohio
Kristen M. Klipfel, PhD, Isaac Ray Forensic Group, LLC, Chicago, Illinois
Glenn J. Larrabee, PhD, ABPP, private practice, Sarasota, Florida
Grace J. Lee, MS, Department of Psychology, Ohio University, Athens, Ohio
Sara M. Lippa, PhD, ABPP, National Intrepid Center of Excellence, Walter Reed National
Military Medical Center, and Department of Rehabilitation Medicine, National Institutes
of Health, Bethesda, Maryland
Paul S. Marshall, PhD, ABPP, private practice, Minneapolis, Minnesota
Phillip K. Martin, PhD, ABPP, Department of Psychiatry and Behavioral Sciences,
University of Kansas School of Medicine–Wichita, Wichita, Kansas
Kristian P. Nitsch, PhD, Shepherd Pathways, Decatur, Georgia
Howard J. Oakes, PsyD, ABPP, Ayer Neuroscience Center, Hartford Hospital,
Hartford, Connecticut
Caleb P. Peck, PsyD, ABPP, Clarus Health Alliance, Norwich, Connecticut
Danielle M. Ploetz, PhD, ABPP, Neuropsychology Department, Fairmount Rehabilitation
Programs, Kennedy Krieger Institute, Baltimore, Maryland
Ryan W. Schroeder, PsyD, ABPP, Department of Psychiatry and Behavioral Sciences,
University of Kansas School of Medicine–Wichita, Wichita, Kansas
Robert D. Shura, PsyD, ABPP, Mid‑Atlantic Mental Illness Research, Education,
and Clinical Center, Salisbury VA Medical Center, Salisbury, North Carolina, and Department
of Neurology, Wake Forest School of Medicine, Winston‑Salem, North Carolina
Jason R. Soble, PhD, ABPP, Department of Psychiatry and Department of Neurology,
University of Illinois College of Medicine, Chicago, Illinois
Jennifer M. Stinson, PhD, ABPP, Department of Neurology, Baylor College of Medicine,
Houston, Texas
Adriana M. Strutt, PhD, ABPP, Department of Neurology, Baylor College of Medicine,
Houston, Texas
Julie A. Suhr, PhD, Department of Psychology, Ohio University, Athens, Ohio
Jerry J. Sweet, PhD, ABPP, Department of Psychiatry and Behavioral Science, NorthShore
University HealthSystem, Evanston, Illinois
Troy A. Webber, PhD, Mental Health Care Line, Michael E. DeBakey VA Medical Center,
Houston, Texas
Series Editor’s Note

The editors of this book, neuropsychologists Ryan Schroeder and Phillip Martin, faced
an interesting conundrum when tackling this project, one not typically encountered while
producing a clinical handbook. Usually, potential book buyers can readily appreciate
how a publication might inform and improve their knowledge and skills from reading
book descriptions, and as a result, they need little enticement to add the book to their
libraries. However, some neuropsychologists in clinical settings might view the current
book as irrelevant to their practices, in that they might not routinely perceive questions of
performance validity as present in their patients. Conversely, forensic neuropsychologists,
while regularly encountering questions regarding performance validity in their cases,
might be tempted to dismiss a book written for clinical nonforensic settings as not perti-
nent to their retained expert roles. Both views could not be further from the truth.
If clinicians have any doubts about the importance of the performance validity test
(PVT) in clinical contexts prior to reading this book, they will come away from this
volume convinced. Schroeder and Martin provide compelling information regarding the
not-­inconsequential rates of performance invalidity in clinical settings (e.g., approxi-
mately 15%) and the large percentage of clinical patients who do not divulge the presence
of external incentives for poor neurocognitive performance to treaters. This means that
neuropsychologists in clinical settings likely encounter questions of performance validity
more often than they estimate. If clinicians are incorrect in their conclusions regarding
the presence of cognitive disability in one in eight assessments, this relatively high error
rate can be expected to cause substantial negative repercussions to large numbers of
patients and families, medical care systems, and society in general. As detailed by the
chapter authors, if patients are judged to have cognitive conditions they in fact do not
have, they can lose driving privileges and the ability to live independently and manage
finances. Erroneous neurocognitive diagnoses can lead to iatrogenesis, in which medical
attention is directed to symptoms/conditions that are not present and locks in a false view
that the patient is dysfunctional, often leading to treatments with poor outcome and/or
harmful side effects.
For forensic neuropsychologists, this book contains highly relevant research summa-
ries that can be readily imported for use in forensic evaluations (e.g., while reading this
book in preparation for writing the foreword, I stumbled upon the exact research citation

ix
x Series Editor’s Note

needed for a current forensic case and of which I was not previously aware!). Informa-
tion contained within this book can assist the forensic expert in effectively addressing
attacks that PVT failures in plaintiffs are due to nonincentive factors, such as psychiatric
conditions, pain, medications, fatigue, apathy, diagnosis threat, cogniphobia, and “cry
for help,” hopefully finally putting to rest the latter, poorly considered, explanation for
noncredible symptoms.
The authors concisely detail the unique responsibilities required in clinical validity
assessments, which differ from roles in the forensic arena. They address the delicate issue
of providing feedback on nonplausible neuropsychological test performance to patients
and families, a skill not required in forensic settings, in which experts are consultants
to attorneys and do not furnish test results to test takers. The authors also carefully
elucidate the various potential feedback options when performance invalidity is present
in a clinical setting, and the pros and cons of each. They make the case for a nuanced
approach in which the clinician does not collude in validating a false presentation of cog-
nitive symptoms, but does adopt an empathic and respectful stance that avoids focus on
the causes of invalidity and instead opens the door to exploration of psychosocial issues
that may be provoking noncredible neurocognitive performance. Report writing is also
thoughtfully addressed, with examples of writing style and terminology that are accurate
and objective, while maintaining a nonaccusatory tone. Ethical considerations, includ-
ing discussion of informed consent and concerns regarding disclosure of the presence of
PVTs within a test battery, are explored.
Chapters summarize currently available PVT methods, along with concise explana-
tions of classification statistics needed for test interpretation. The conflicting literature
on whether use of increasing numbers of PVTs is associated with increased false-­positive
rates is summarized and critiqued, and recommendations are provided as to how to avoid
false-­positive identification of invalid test performance.
Other chapters cover such issues as the use of PVTs with ethnic minority and non-­
native English speakers; veterans and military personnel; children and adolescents;
patients with psychiatric conditions, including somatic symptom and related disorders;
patients with mild traumatic brain injury; and patients in memory disorders clinics, in
rehabilitation settings, and undergoing academic evaluations. Psychological underpin-
nings of postconcussive syndrome symptoms are addressed, and information is provided
on how to prevent postconcussive syndrome from developing, as well as treatment meth-
ods once it does emerge. Helpful descriptions of the Social Security disability and Work-
ers Compensation systems are included, along with discussion of the role of PVTs in these
settings. The relationships between MMPI-­2-­R F and PVT data are summarized, which
can be applied to the MMPI-­3, given the high correlations between scales on the two per-
sonality inventory instruments. The book concludes with a chapter that offers a roadmap
for clinical neuropsychologists regarding terms and procedures within the forensic arena,
should they find themselves invited to participate.
In conclusion, in this practical and comprehensive book, the editors and chapter
authors have clearly met their goal of providing guidelines for “ethical, efficient, and
accurate validity assessments” within clinical/nonforensic neuropsychological settings.

Kyle Brauer Boone, PhD

The University of California, Los Angeles
Preface

Over the last two decades, neuropsychologists saw a dramatic expansion of the litera-
ture base related to neuropsychological validity assessment. A multitude of peer-­reviewed
journal articles was published, and excellent books on forensic assessment and malinger-
ing of cognitive dysfunction became available. Books authored or edited by Kyle Boone,
Glenn Larrabee, and Dominic Carone and Shane Bush, in particular, shaped our own
thinking on neuropsychological validity assessment. In applying concepts from these and
other largely forensic texts to our clinical patients, we recurrently recognized the salient
differences between forensic and clinical practice. We also became increasingly cogni-
zant that these differences carried important implications when attempting to generalize
validity assessment practices from forensic settings to clinical settings. Given this, and
given the relative lack of literature addressing validity assessment in nonforensic settings,
we became interested in understanding how other clinicians manage invalidity in their
clinical patients. As a result, we conducted surveys with both national samples of neuro-
psychologists and a select group of neuropsychological validity testing experts, exploring
their beliefs and practices regarding validity-­related practice issues in both clinical and
forensic settings. The survey results confirmed our suspicions that (1) most neuropsychol-
ogists frequently utilized and relied on validity assessment in their forensic and clinical
evaluations, but (2) contrary to forensic contexts, consensus about managing invalidity
in clinical contexts was generally lacking.
In the ensuing years since publishing these surveys, we have continued to conduct
our own research of validity assessment practices in clinical nonforensic settings, and we
have connected with other experts who also seek to further advance such practices in this
milieu. In this book, we, along with our skilled colleagues, who are among the foremost
experts on the topics in their respective chapters, discuss nuanced validity assessment
issues and apply them to nonforensic settings. Part I of the book explores validity assess-
ment phenomena and challenges unique to the nonforensic clinical setting, providing
direction on how to manage clinical patients when they invalidate testing. Conceptual
and empirical data, practical techniques and recommendations, case illustrations, and
sample reports are all provided to augment clinical learning. Part II of the book examines
clinical and methodological factors requiring consideration before, during, and after the
evaluation. Within these chapters, information on potential biases, appropriate validity

xi
xii Preface

test cutoffs, application of validity test cutoffs to ethnic minorities and non-­native Eng-
lish speakers, and methods to synthesize data to reach firm empirical conclusions are
discussed. Part III of the book provides guidance for addressing invalidity in specific
settings, contexts, and populations in order to facilitate evidence-­based validity assess-
ment practice for the individual patient. The section concludes with a “hands-on” guide
describing how to appropriately engage in legal proceedings in instances where clinical
cases turn forensic in nature. Our hope is that this book will help guide the majority of
clinicians who utilize validity assessment in their nonforensic evaluations but who, like
us, recognize that some forensic concepts cannot be easily adapted to clinical settings.
In closing, we would like to acknowledge individuals whom we are very grateful to
have in our professional lives. Ryan would like to thank everyone who has contributed to
his professional training as a psychologist and neuropsychologist. He would also like to
thank Paul Marshall, Lyle Baade, Kyle Boone, Glenn Larrabee, Jerry Sweet, and Robert
Heilbronner, who heavily shaped his conceptualization of validity issues and provided
additional opportunities to increase his engagement in this particular area of scholarly
interest. Phillip would like to thank Laurence Levine and Ryan Schroeder for helping to
foster both his interest in and conceptualization of validity assessment issues in clinical
practice, as well as Don Morgan, Charles Golden, and Lyle Baade for their training, men-
torship, and professional guidance. Both Ryan and Phillip would also like to thank Kyle
Boone for her great generosity in all that she has done for us, including recommending us
to Rochelle Serwator, Senior Editor at The Guilford Press. We would also like to thank
Rochelle for her guidance and support in creating this book. Finally, we would like to
thank all of the chapter authors whose work appears in this book for their eager willing-
ness to devote days’ worth of their time to generously contribute to the knowledge and
guidance that is contained here.
Contents

PART I. Neuropsychological Validity Assessment:

Important Distinctions for Nonforensic Practice

1. Validity Assessment in Clinical Settings: 3

How It Differs from Forensic Settings and Why It Is Important
Ryan W. Schroeder and Phillip K. Martin

2. Explanations of Performance Validity Test Failure 11

in Clinical Settings
Ryan W. Schroeder and Phillip K. Martin

3. Malingering: Maintaining a Perspective of Clinical Care 31

When Patients Feign
Phillip K. Martin and Ryan W. Schroeder

4. A Framework for Providing Clinical Feedback 47

When Patients Invalidate Testing
Phillip K. Martin and Ryan W. Schroeder

5. Incorporation of Validity Assessment and Validity Findings 70

When Writing Clinical Reports
Ryan W. Schroeder and Phillip K. Martin

6. Ethical Considerations Associated with Validity Assessment 86

in Clinical Evaluations
Phillip K. Martin, Ryan W. Schroeder, Kyle Brauer Boone,
and Shane S. Bush

xiii
xiv Contents

PART II. Clinical and Methodological Considerations

Throughout the Evaluation

7. Clinical Judgment and Clinically Applied Statistics: 107

Description, Benefits, and Potential Dangers When Relying
on Either One Individually in Clinical Practice
Brechje Dandachi‑FitzGerald and Phillip K. Martin

8. An Overview of Common Performance Validity Tests 126

for Practicing Clinicians: Cutoffs, Classification Accuracy,
and Administration Times
Jason R. Soble, Troy A. Webber, and K. Chase Bailey

9. The MMPI‑2‑RF Validity Scales: An Overview of Research 150

and Applications
Jordan T. Hall and Yossef S. Ben‑Porath

10. The Nuts and Bolts of Incorporating Validity Assessment 179

in Clinical Evaluations
Sara M. Lippa

11. Synthesizing Data to Reach Clinical Conclusions 193

Regarding Validity Status
Glenn J. Larrabee

12. Performance Validity Testing with Culturally Diverse Individuals 211

and Non‑Native English Speakers: The Need for a Cultural Perspective
in Neuropsychological Practice
Adriana M. Strutt and Jennifer M. Stinson

PART III. Validity Assessment in Specific Clinical Settings and Contexts

13. Validity Assessment within Veterans Affairs and Active Duty Settings 235
Robert D. Shura, John H. Denning, Patrick Armistead‑Jehle,
and Bradley N. Axelrod

14. Validity Assessment within the Memory Disorders/Dementia Clinic 254

Ryan W. Schroeder and Phillip K. Martin

15. Validity Assessment within the Rehabilitation Setting 280

Jeremy J. Davis
Contents xv

16. Validity Assessment in Academic Evaluations 300

Julie A. Suhr, Grace J. Lee, and Kaley Angers

17. Validity Assessment in Patients with Psychiatric Disorders 319

Paul S. Marshall and Ryan W. Schroeder

18. Validity Assessment in Patients with Mild Traumatic Brain Injury 338
Ryan W. Schroeder, Phillip K. Martin, and Glenn J. Larrabee

19. Validity Assessment in Patients with Somatic Symptom 357

and Related Disorders
Christopher J. Graver and Kyle Brauer Boone

20. Validity Assessment for Clinical Patients 378

Pursuing Social Security Disability
Ryan W. Schroeder and Michael Chafetz

21. Validity Assessment for Clinical Patients 400

with Workers’ Compensation Claims
Caleb P. Peck and Howard J. Oakes

22. Validity Assessment with Children and Adolescents: 418

Comparisons to Adult Evaluations
Danielle M. Ploetz, Carolyn T. Caldwell, and Kristian P. Nitsch

23. Forensic Primer for the Nonforensic Neuropsychologist: 439

When Clinicians Participate in Forensic Proceedings
Jerry J. Sweet and Kristen M. Klipfel

Index 463
VALIDITY ASSESSMENT
IN CLINICAL NEUROPSYCHOLOGICAL PRACTICE
PA R T I

Neuropsychological
Validity Assessment
Important Distinctions for Nonforensic Practice
 CHAPTER 1

Validity Assessment in Clinical Settings

How It Differs from Forensic Settings and Why It Is Important

Ryan W. Schroeder and Phillip K. Martin

VALIDITY ASSESSMENT: GROWING FROM FORENSIC TO CLINICAL SETTINGS

Historically, it was believed that nearly all individuals who underwent neuropsycho-
logical testing for clinical purposes produced valid data (Green & Merten, 2013; Mit-
tenberg, Patton, Canyock, & Condit, 2002). This was likely because clinicians held a
perspective that essentially all clinical patients were motivated to receive accurate and
clinically helpful information regarding their health care questions. In contrast, it was
known that individuals who underwent neuropsychological testing for forensic purposes
had clear external incentives to malinger (e.g., obtain financial compensation or avoid
criminal responsibility). As a result, it was thought that production of invalid data on
neuropsychological testing was a phenomenon that primarily occurred in forensic evalu-
ations (Merten et al., 2013; ­M ittenberg et al., 2002). Correspondingly, much of the early
research on neuropsychological validity assessment was conducted in forensic settings,
by forensic practitioners, and for forensic practitioners (Suchy, 2019). Given the forensic
nature of this research, invalidity was largely considered synonymous with malingering,
validity tests were sometimes called “malingering tests,” and the most commonly used
performance validity test (PVT) in North America was even named the Test of Memory
Malingering (TOMM; Martin, Schroeder, & Odland, 2015; Mittenberg et al., 2002;
Nies & Sweet, 1994; Slick, Tan, Strauss, & Hultsch, 2004).
Over time, research on neuropsychological validity assessment began to increase
in both volume and scope (Martin et al., 2015; Suchy, 2019). As noted by Martin et al.
(2015), in the mid-1990s, roughly 7% of articles published in two commonly referenced
neuropsychology journals, Archives of Clinical Neuropsychology and The Clinical Neu-
ropsychologist, addressed topics regarding neuropsychological validity assessment. By
the mid-2010s, however, roughly 25% of articles investigated topics related to neuropsy-
chological validity assessment (see Figure 1.1). With this expansion in empirical inves-
tigation, the focus of the research began to shift from detecting malingering in forensic
settings to understanding the effects of performance invalidity more generally, whether
in forensic or clinical settings (Suchy, 2019).

3
4 N e u r o p s y c h o l o g i c a l Va l i d i t y A s s e s s m e n t

30%

25%

20%

15%

10%

5%

0%

FIGURE 1.1. Average proportion of articles published on neuropsychological validity assessment

by year in The Clinical Neuropsychologist and Archives of Clinical Neuropsychology. Data from
Martin, Schroeder, and Odland (2015).

In a seminal study, Mittenberg et al. (2002) documented that invalidity occurred in

clinical nonforensic settings, albeit less frequently than in forensic settings. Green, Roh-
ling, Lees-Haley, and Allen (2001) found that when patients completed testing invalidly,
the invalidity significantly impacted cognitive test performance, as it explained roughly
50% of the variance in cognitive test scores. This was notably more variance than that
accounted for by age (4%), education (11%), Glasgow Coma Scale score (1%), degree of
posttraumatic amnesia (1%), and presence of positive neuroimaging findings (<1%). The
utility of formal approaches to detect invalidity also became abundantly evident. For
example, Larrabee (2003) found that accurate identification of invalidity via concurrent
use of multiple validity tests far exceeded the classification accuracy rates achieved by
use of clinical judgment alone (see Faust, Hart, & Guilmette, 1988a; Faust, Hart, Guil-
mette, & Arkes, 1988b; Heaton, Smith, Lehman, & Vogt, 1978). Similarly, Meyers and
Volbrecht (2003) demonstrated that use of multiple validity tests resulted in strong clas-
sification accuracy rates, even in nonforensic clinical samples.
As a result of the expanded literature base, it became clear that validity assessment
should be considered a critical and core component of all neuropsychological evalua-
tions, a perspective that was adopted and documented by several well-cited professional
position papers. With regard to incorporating validity testing in clinical evaluations, spe-
cifically, the National Academy of Neuropsychology released a validity testing position
paper in 2005, emphasizing that “adequate assessment of response validity is essential in
order to maximize confidence in the results of neurocognitive and personality measures
and in the diagnoses and recommendations that are based on the results” (Bush et al.,
2005, p. 419). The position paper further elaborated that “assessment of response valid-
ity, as a component of a medically necessary evaluation, is medically necessary” (p. 419).
Validity Assessment in Clinical Settings 5

Two years later, the American Academy of Clinical Neuropsychology (AACN) released
practice guidelines for neuropsychological assessment and consultation (Board of Direc-
tors, 2007). Within these practice guidelines, it was specified that “the assessment of
effort and motivation is important in any clinical setting, as a patient’s effort may be
compromised even in the absence of any potential or active litigation, compensation,
or financial incentives” (p. 221). In 2009, the AACN released a consensus statement
focused on the use of neuropsychological validity testing (Heilbronner et al., 2009) and
stated that “response bias may occur in routine clinical and medical referrals, when no
forensic context is evident” and “when clinicians are evaluating a (nonforensic) patient
who by virtue of claimed injuries is reasonably likely to become a litigant or claimant,
the clinician should consider the increased risk of insufficient effort and response bias”
(pp. 1105–1106).
Organizations outside of neuropsychology also began to emphasize the need for
validity assessment in neuropsychological evaluations. For example, the American Medi-
cal Association’s guides to the evaluation of permanent impairment (American Medical
Association, 2008) stated that “it is standard practice that a neuropsychological test bat-
tery should include instruments that include . . . validity tests” (p. 351). The Institute of
Medicine of the National Academies (Institute of Medicine, 2015), a nonprofit institution
that provides independent objective analysis to inform public policy decisions, declared
that “it is important to include an assessment of performance validity at the time cogni-
tive testing is administered” (p. 202). It was further stated that “all cognitive evaluations
should include a statement of evidence of the validity of the results” (p. 203).
By virtue of the robust literature base and ensuing organizational practice recom-
mendations, most neuropsychologists are now aware that invalid test performance and
symptom report can occur in many contexts, even within routine clinical contexts in
which external incentives to underperform are absent (Martin et al., 2015; Martin &
Schroeder, 2020; Sweet, Benson, Nelson, & Moberg, 2015). This is a particularly impor-
tant concept to appreciate given that neuropsychologists evaluate cognitive and emo-
tional statuses (Board of Directors, 2007), aspects of human functioning that cannot be
quantified by methods such as laboratory values, neuroimaging findings, or electrophysi-
ological procedures—­tests that are relatively impervious to patient behavior (Schroeder,
Martin, & Walling, 2019). Assessment of cognitive and emotional capabilities relies heav-
ily on patient engagement, motivation, and cooperation (Bianchini, Mathias, & Greve,
2001). Thus, if a patient provides suboptimal engagement, motivation, or cooperation,
or produces test data or symptom report with the intent to deceive, his or her cognitive
and emotional functioning cannot be accurately captured. If a clinical patient’s inac-
curate results are erroneously identified as being accurate, the neuropsychologist could
inadvertently harm the patient by (1) providing inaccurate and emotionally impactful
diagnoses (e.g., telling a patient that he or she has significant persistent cognitive deficits
or even a neurodegenerative condition), (2) reinforcing noncredible symptoms, (3) recom-
mending unnecessary and potentially costly additional workup (e.g., magnetic resonance
imaging [MRI] of the brain), (4) recommending unnecessary and potentially harmful
treatment (e.g., unneeded medication prescription), and/or (5) recommending restrictions
to daily living activities and/or independence (e.g., stopping driving or moving from inde-
pendent living to assisted/sheltered living). As demonstrated by this historical review,
neuropsychological validity assessment has clearly evolved over time, and neuropsycho-
logical validity tests are no longer viewed as simply being tools for detecting malinger-
ing, primarily in forensic settings. Rather, validity assessment is now viewed as a means
to ensure accuracy of neuropsychological test data regardless of cause of invalidity and
6 N e u r o p s y c h o l o g i c a l Va l i d i t y A s s e s s m e n t

clinical setting, a sentiment that is reinforced by the updated AACN validity assessment
consensus statement (Sweet et al., 2021).

DIFFERENCES IN VALIDITY ASSESSMENT

BETWEEN CLINICAL AND FORENSIC EVALUATIONS
As previously described, it is now clear that validity assessment should be incorporated
within all neuropsychological evaluations, including clinical nonforensic evaluations.
On the surface, addressing validity issues in nonforensic evaluations might seem to be a
straightforward task given that a significant amount of literature has amassed on validity
assessment in forensic settings, and the basic elements of a neuropsychological evaluation
are largely the same in clinical and forensic evaluations (see Table 1.1). When attempting
to apply the large forensic literature base to clinical settings, however, it becomes obvious
that there are differences in assessing validity status, interpreting and documenting valid-
ity test results, and providing feedback to others when validity tests are failed. In order to
understand the differences in validity assessment that are related to practice setting, it is
imperative that neuropsychologists be aware of the core distinctions between clinical and
forensic evaluations, a topic that we discuss next.
As there is not yet a consensus-­achieved, formal definition of what constitutes a
clinical (as opposed to forensic) neuropsychological evaluation, we provide the follow-
ing operational definition of a clinical neuropsychological evaluation, which is based on
previously published descriptions of services provided (i.e., Binder, 2019; Donders, 2016;
Sweet, Kaufmann, Ecklund-­Johnson, & Malina, 2018). We define a clinical neuropsy-
chological evaluation as an evaluation where a neuropsychologist provides health care
services to a patient who is seeking treatment for a malady. In providing this evaluation,
the neuropsychologist is acting as a treating doctor (a term applied regardless of whether
assessment or intervention is directly provided) and entering into a patient–­doctor rela-
tionship.
To highlight the distinguishing features of the clinical neuropsychological evalua-
tion, we unpackage the aforementioned definition. First, because a neuropsychologist

TABLE 1.1. Basic Elements of Neuropsychological Evaluations

Clinical evaluations Forensic evaluations

Accept referral Yes Yes

Review records Yes Yes
Obtain informed consent Yes Yes
Conduct clinical interview Yes Yes
Complete testing Yes Yes
Interpret data Yes Yes
Reach conclusions Yes Yes
Write report Yes Yes
Provide feedback to patient Yes No
Validity Assessment in Clinical Settings 7

provides health care services to a patient, that neuropsychologist is operating within a

health care system. As such, other health care providers often serve as the referral source,
referring individuals with diverse clinical conditions, including significantly impactful
conditions such as dementia (Sweet et al., 2015). The neuropsychologist evaluates and/or
treats these patients, typically billing medical insurance for rendered services (Donders,
2016; Sweet et al., 2018). By billing medical insurance, the neuropsychologist agrees to
the stipulations set forth by insurance companies, which includes time-limit restrictions
on how much testing can be completed (Lamberty, 2012). Accordingly, survey data show
that reimbursement factors and evaluation context (i.e., clinical or forensic evaluation)
are both cited by neuropsychologists as factors that impact length of the neuropsycho-
logical evaluation (Sweet et al., 2015).
Second, because neuropsychologists conducting clinical evaluations are acting as a
treating doctor by entering into a patient–­doctor relationship, it is expected that the
exam is designed to provide information that will clinically benefit the patient (Binder,
2019). The neuropsychologist typically provides a clinical opinion to the patient (Binder,
2019), acts as an advocate for the patient (Donders, 2016), and attempts to minimize
harm to the patient (Binder, 2019). Additionally, within clinical evaluations, it is gen-
erally understood that confidentiality is protected except under special circumstances
(Donders, 2016).
Whereas operating as a treating doctor and entering into a patient–­doctor relation-
ship are key features of the clinical neuropsychological evaluation, such characteristics
are incongruent with accepted definitions and principles of forensic practice. According
to the American Psychological Association (2013), a forensic evaluation is one in which
the psychologist applies scientific, technical, or specialized knowledge of psychology to
the law to assist in addressing legal, contractual, and/or administrative matters. Stated
more simply, a forensic neuropsychological evaluation is one in which neuropsycholo-
gists apply neuropsychological knowledge and facts to answer legal questions (Larrabee,
2012; Greiffenstein & Kaufmann, 2018).
The aforementioned definition of a forensic neuropsychological evaluation can
be unpackaged to show how it differs from a clinical neuropsychological evaluation.
Because forensic neuropsychologists apply knowledge to the law to answer legal ques-
tions, attorneys or administrative professionals often serve as the referral source (Sweet
et al., 2018). Forensically referred examinees often have relatively restricted causes of
their cognitive complaints, with trauma-­based conditions, such as traumatic brain injury,
being frequently claimed (Sweet et al., 2015). Because the goal of the evaluation is to
answer legal questions, the neuropsychologist is expected to provide an impartial impres-
sion in which considerations of accuracy clearly trump those of examinee well-being
(Sweet et al., 2018).
Because, within a forensic evaluation, the neuropsychologist does not practice within
a typical health care system or provide health care services to the examinee, the neu-
ropsychologist does not form a doctor–­patient relationship with the examinee (Binder,
2019). Additionally, the neuropsychologist does not bill medical insurance; therefore,
the neuropsychologist is not confined to the limits imposed by insurance reimbursement
policies (Lamberty, 2012). Furthermore, the neuropsychologist has no obligation to help
the examinee and is not an advocate for the examinee; instead, he or she is an advocate
for the truth (Binder, 2019). Because it is known that the “truth” is often exaggerated
or feigned within forensic settings (Larrabee, Millis, & Meyers, 2009; Mittenberg et al.,
2002), the neuropsychologist might be inclined to view the examinee more skeptically
than in clinical settings (Bush & Heilbronner, 2012). Finally, because healthcare laws are
8 N e u r o p s y c h o l o g i c a l Va l i d i t y A s s e s s m e n t

not pertinent in forensic evaluations and the results of the evaluation will become part of
a public record, there is not the same legal mandate to protect an examinee’s confidential-
ity as there is within the clinical evaluation (Sweet et al., 2018).
The key differences that distinguish clinical from forensic neuropsychological evalu-
ations (as just described and as summarized in Table 1.2) translate into important dif-
ferences in validity assessment practices, which are described in Table 1.3. In addition
to recognizing these individual differences, one should also recognize that clinical and
forensic neuropsychologists are likely to proceed with the evaluation in different man-
ners given the different factors/goals inherent within the evaluations. Specifically, while
both types of neuropsychologists should recognize that the consequence of validity test
failure is the same (i.e., do not interpret neuropsychological test data as accurate), the
resultant interpretive question will likely be different. In forensic settings, the question
is often “What does this say about the examinee and his or her claims?” In clinical set-
tings, however, the operative question is likely more appropriately “How can I provide
useful clinical services when I have invalid test data?” Given the many differences in
validity assessment practices and interpretive questions, it should be understood that it is
not always possible or appropriate to generalize research findings, practice recommenda-
tions, or guidelines from forensic literature to practice in the clinical nonforensic setting.
Because of issues in generalizing forensic literature to nonforensic cases, and because
there is limited guidance in addressing methods and approaches to validity assessment
in clinical settings, managing invalidity in nonforensic settings is arguably more chal-
lenging than managing invalidity in forensic settings. In this book, therefore, we aim to
thoroughly examine the validity assessment literature through the lens of clinical practice
in order to provide guidance and resources for utilizing and addressing validity assess-
ment in nonforensic settings. Chapters 6–12 provide resources on how to conduct ethi-
cal, efficient, and accurate validity assessments in clinical settings. Guidance on how to
move forward when PVTs are failed, including ways to conceptualize invalidity in clinical
settings (Chapters 2–4), provide feedback when testing is invalid (Chapter 4), and write
clinically useful reports when testing is invalid (Chapter 5) are also provided. Discussions
of validity assessment in specific clinical settings and contexts are also provided in the

TABLE 1.2. Key Factors Differentiating Clinical and Forensic Neuropsychological Evaluations
Clinical evaluations Forensic evaluations

Doctor–patient relationship No doctor–patient relationship

Address health care questions Address legal questions

Advocate for patient Advocate for truth

Goal: objectivity, accuracy, and patient well-being Goal: objectivity and accuracy

Notable limits on amount of time to conduct Minimal limits on amount of time to conduct
evaluations evaluation

Invalidity is often less common Invalidity is often more common

Patient obtains results Third parties obtain results

Confidentiality strongly protected Less confidentiality

Validity Assessment in Clinical Settings 9

TABLE 1.3. Examples of How Key Differences between Clinical and Forensic Evaluations
Impact Validity Assessment
1. Time to review records to ensure accurate report of history and symptoms is less in clinical settings.
2. Clinical patients present with highly diverse diagnostic conditions, including dementia, which can
impact validity assessment.
3. Time-efficient validity assessment is more necessary in clinical settings than in forensic settings.
4. Differing base rates of invalidity impact interpretation of PVTs via influence of positive and
negative predictive power.
5. Base rates of causes of invalidity in each setting can impact conclusions drawn regarding reasons
for invalid test findings.
6. There is a need to balance validity considerations with treatment recommendations in clinical
settings.
7. Report-writing goals and/or styles vary based on differences in time limits and expectations
inherent in each setting.
8. Feedback is provided to the patient in clinical settings versus a third party in forensic settings.

last section of this book (Chapters 13–22). Finally, Chapter 23 includes information on
conceptualizing legal matters and responding to queries when clinical cases turn forensic
in nature.

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