Article summary with Clinical strategies to assess the credibility of presentations in children by Carone - 2015

Objective measures to assess if a person is reporting valid symptoms or performing validly are known as effort tests, symptom validity tests, or performance validity tests (PVT). There are more PVTs available for adults than for children. The PVTs that are available are sometimes not applicable to children because they are too young, or have a low reading level for example. This means that next to PVTs, clinicians often need to use other methods to determine the validity of a child's response. An example of this is to use the Slick criteria:

• Finding evidence there is a big external incentive for the person doing the test, meaning they are more likely to show a negative response bias.
• Finding a discrepancy between test data and observed behavior or background history.
• Finding a discrepancy between test data and what we know about how the brain functions or how a certain psychological, physical or cognitive problem develops.
• Finding a discrepancy between self-reported history and documented history, what we know about certain problems and how they develop, behavioral observations or reports from others.

These Slick criteria force neurpsychologists to use and combine many different types of data to determine whether someone is showing a credible or a noncredible response. This process is known as coherence analysis, and can be remembered through the seven C's:

• Continuity: does someone progress in the way we expect based on what we know about the problem?
• Consistency: does someone show a consistent presentation of the problem over time?
• Congruence: are the different aspects of someone's clinical presentation compatible?
• Compliance: is someone willing to do assessments and follow treatment?
• Causality: is the problem someone states the cause of what they are experiencing or is there an alternative explanation?
• Comorbidity: are there other factors present that could explain the clinical presentation of the patient?
• Cultural factors: are there any cultural difference factors that might explain what the patient is experiencing and their clinical presentation?

How can we understand the context of nonclinical presentations in children?

Many children show up to a neuropsychological evaluation not exactly knowing why they are there in the first place. Many parents have told them they will see a doctor who will do some tests to help them. This means that some of them show up upset because they have to do something they dislike (tests). Next to this, some children can be aware of the compensation family members receive for being sick, either in the form of money or attention. This can influence the child's behavior: they may become attention seeking and may perform different on neuropsychological tests. Furthermore, psychosocial factors can play a role as well for children. Examples of this are divorce or being bullied in school. The child may also suffer from comorbid conditions that influence their behavior. A clinician needs to take the complete context and the child as a person into account to make better observations and do more accurate testing.

Which behavioral observations can a clinician make during interviews or testing that may indicate noncredible responding?

• Signs of passive negativity or agressiveness. These signs from the child can include not making eye contact, sighing, quick short interview answers or not verbally acknowledging the clinician at all. These can also be shown in signs of family tension such as arguments. Before interpreting these signals a clinician must make sure these things are not caused by depression, shyness or a neurodevelopmental disorder.
• Signs of active negativity or agressiveness. These signs from a child include comments about being examined, crying, yelling, or negative comments towards the clinician.
• Repeated signs that the child has a desire to leave. This can be seen if children repeatedly whine, sigh or cry while asking to go. Many children check the clock a lot, ask for breaks, or leave.
• Signs of separation anxiety. Separation anxiety is seen when a child leaves the presence of their caretaker or parent. Signs of it are crying, trying to find the adult, or asking to leave to be with the adult. What can help is explaining to the child what will happen, reassuring them the parent is nearby, or even letting the parent sit in on the evaluation. Some children show separation anxiety immediately, whereas others do not and only start crying at the end of the evaluation. An examiner then has to consider doing the evaluation again, because the results may have been influenced by the anxiety and stress.
• Signs of poor engagement with testing. Examples of this are sleepy behaviors, or not sticking to the instructions of the test, quickly saying they do not know the answer or providing the same or alternating responses to yes/no questions on an interview or a questionnaire.

How can we review school records?

Information that is subjective, observational and descriptive but can give us an idea of a child's effort in class includes progress notes, comments by teachers or school therapists or report cards. Another thing that can be gotten from school records is teacher observations about a child's off-task behaviors in class. These may be a sign a child has an actual neuropsychological problem or it may be poor effort. School records can not only show qualitative in the moment information, but can also give a clinician quantitative information about a trend in the behavior of the child.

How can we review information gathered in medical settings?

How can we evaluate physical signs of noncredible presentation?

A first indicator of noncredible effort is when someone shows inconsistencies in their performance across tasks. Another way to determine a physical response bias is distracting the patient from the symptoms and their impact, to see if the self-reported functioning of a patient matches clinical observations during a task. Furthermore, there could be looked at physical presentations of a patient over time, or possible discrepancies between how someone behaves during an examination and during other times in their life.