A-40 Predictors of Failed Effort Testing at Initial Clinic Visit for Concussion Rehabilitation and Outcomes

Objective Neuropsychological evaluation of concussion typically includes performance validity testing to assess effort. The aim of this study was to explore the usefulness of effort testing as part of initial screening for concussion rehabilitation, including determining the factors that predict effort testing and evaluate outcomes between “good effort” and “failed effort” groups. Method Records of 76 patients aged 16–66 years old (M = 40.58 years, SD = 14.18) seen for rehabilitation of non-sport concussion from 2018–2019 were reviewed. Patients completed clinical interview, neurocognitive screening (ImPACT), effort testing (Word Memory Test), vestibular/oculomotor screening (VOMS), and the post-concussion symptom scale (PCSS). A logistic regression (LR) was conducted to predict effort, with predictors including mental health history, secondary gain, work injury, days post-injury, and PCSS. A series of one-way ANOVAs evaluated outcomes from concussion rehabilitation between the good and failed effort groups. Results Failed effort occurred in 42% of cases. The LR accurately classified 81.8% of individuals, with mental health history (p = .01) and PCSS (p = .02) as the only significant predictors of effort. There were no differences in recovery time (p = .56) between effort groups, but the failed effort group took longer to return to work (p = .03). Half of individuals who failed effort were seen until discharge, and 69% of them reported no symptoms/mild symptoms at discharge. Conclusions Failure of effort testing was predicted by a history of mental health and high symptom burden. Individuals who fail effort testing at initial visit for concussion rehabilitation take longer to return to functional activity but are capable of achieving recovery with compliance and appropriate rehabilitation.

A-02 Multifaceted Treatment of Sports Concussions and Resulting Conversion Disorder: A Case Study

Objective This case illustrates the complexities of concussion resulting in Conversion Disorder, rarely discussed in the literature, in a 12-year-old female. Diagnosis, treatment, and recurrence of symptoms through three injuries and retirement from sports are presented. Method Initial injury, with disorientation and amnesia, occurred following three impacts during a soccer tournament. Patient was a high average student, in a divorced family, who recently lost her maternal grandfather and began middle school. Subsequent to initial injury, she reported a loss of memory for all family members, colors and numbers. Family was seen by Neurology, multi-disciplinary Concussion Clinic (CC) providers, and cranial MRI was completed. Neuropsychological testing included IQ, academics, memory, executive functions, emotional, and effort testing. Return to play occurred seven months later, although school avoidance continued through a second injury. A third injury occurred 32 months after initial injury, with additional neuropsychological testing and retirement. Interventions included alternating courses of cognitive-behavioral therapy, family interventions, headache clinic, academic modifications, psychiatry, and continuous CC follow-up. Results All imaging results were normal. Neuropsychological results were average to above average in all areas except calculation tasks and effort testing, with minimal change over time. Significant relation between emotional symptoms, social stressors, self-concept, and cognitive symptoms supported Conversion Disorder. Lack of clearance to return to play motivated initial recovery. Multiple courses of varied interventions addressed complex self-identity issues. Conclusions As research indicates, diagnosis of conversion requires medical and psychological methods. The complex components of this case highlight change resulting from a CC coordinating equally complex medical and psychological treatment.

Does Validity Measure Response Affect CPT Group Outcomes in Veterans with PTSD?

Introduction There is a dearth of research on the impact of pre-treatment assessment effort and symptom exaggeration on the treatment outcomes of Veterans engaging in trauma-focused therapy, handicapping therapists providing these treatments. Research suggests a multi-method approach for assessing symptom exaggeration in Veterans with posttraumatic stress disorder (PTSD), which includes effort and symptom validity tests, is preferable. Symptom exaggeration has also been considered a “cry for help,” associated with increased PTSD and depressive symptoms. Recently, research has identified resilience as a moderator of PTSD and depressive symptom severity and an important predictor of treatment response among individuals with PTSD. Thus, it is important to examine the intersection of symptom exaggeration, resilience, and treatment outcome to determine whether assessment effort and symptom exaggeration compromise treatment response. Materials and Methods We recruited Veterans, aged 18–50 who served during the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) era, from mental health clinics and fliers posted in a large Veterans Affairs Medical Center. Veterans met inclusion criteria if they were diagnosed with PTSD via a clinician-administered assessment. Sixty-one Veterans consented to participate and self-selected into a cognitive processing therapy (CPT) group or treatment-as-usual. We offered self-selection because low recruitment rates delayed treatment start dates and were consistent with a Veteran-centered care philosophy. Veterans were assessed before and after treatment to determine the impact of assessment effort and symptom exaggeration scores on measures of PTSD and depressive symptoms and resilience. This study examined whether assessment effort failure and symptom exaggeration were associated with compromised psychotherapy outcomes in Veterans with PTSD undergoing CPT group. We hypothesized that a pattern of responding consistent with both effort and symptom exaggeration would result in higher (ie, more severe) pre- and post-treatment scores on PTSD and depressive symptom outcome measures and lower resiliency when compared to Veterans providing good effort and genuine responding. Hypotheses were evaluated using bivariate correlation analyses, analysis of variance, and chi-square analyses. Results Pre-treatment scores on measures of PTSD and depressive symptoms were higher among Veterans whose pattern of responding was consistent with poor assessment effort and symptom exaggeration; these Veterans also scored lower on a measure of resiliency. At post-treatment, there were no differences between Veterans displaying good and failed effort testing on measures of PTSD and depressive symptoms or in whether they completed treatment. Post-treatment resiliency scores remained significantly lower in those with failed effort testing. Conclusion These results suggest that Veterans with PTSD whose validity testing scores are indicative of poor effort and symptom exaggeration may be less resilient but may still complete a CPT group treatment and benefit from treatment at a rate comparable to Veterans who evidence good assessment effort and genuine symptom reporting pre-treatment. These findings also challenge the assumption that pre-treatment assessment effort failure and symptom exaggeration accurately predict poor effort in trauma-focused psychotherapy.

B-53 Inefficient Clock-Checking is Associated with Reduced Prospective Memory Performance in Veterans with Blast-Related Mild Traumatic Brain Injury

Objective We investigated whether clock-checking frequency during a prospective memory (PM) task differed between Veterans with reported histories of blast-related mild traumatic brain injury (mTBI) and Veteran Controls (VCs) without a history mTBI. We hypothesized that, compared to controls, the mTBI group would less frequently clock check. Additionally, we expected that reduced clock-checking would contribute to poorer time-based PM performance in the mTBI group. Method Twenty-seven Veterans (9 mTBI and 18 VC) with sufficient effort testing completed a structured TBI history interview, the Post-Traumatic Stress Disorder Checklist (PCL) and the Memory for Intentions Test (MIST) as a PM task. During MIST administration, examiners recorded clock-checking behavior each time a participant physically turned a digital clock to observe the current time. Results Compared to VCs, the mTBI group performed worse on the Time subscale of the MIST [Mean (SD) VC = 6.7 (1.1), mTBI = 5.7 (1.1), p < .05], and demonstrated significantly fewer clock-checks over the duration of the test [VC = 14.2(4.7), mTBI = 10.2 (3.4), p < .05]. Clock-checking significantly correlated with MIST Time subscale performance (r = .38, p < .05). Groups did not significantly differ in PCL scores, and PCL scores did not significantly correlate with clock-checking counts. Conclusion Our preliminary results are the first to show that clock-checking behavior may contribute to reduced performance on time-based PM tasks in Veterans with histories of mTBI. Specifically, our findings demonstrate that participants with mTBI employ an inefficient time monitoring strategy wherein infrequent clock checking contributes to poorer test performance. These findings suggest that strategies to improve clock checking may improve PM performance.

C-68 Expanding Pediatric Performance Validity Tests

Objective Effort testing with children has started to gain traction in the literature. The following case presents data from several number recall tasks similar to the Wechsler Digit Span and may expand the opportunities for embedded performance validity tests (PVTs). Method For the purpose of psychoeducational testing, a comprehensive battery of standardized neuropsychological tests was administered, including visual and auditory attention, language, visual-motor and fine motor skills, visual and auditory processing, executive functioning, and academics. Results The child showed impaired performance on Number Recall from the Kaufman Assessment Battery for Children, 2nd Edition (KABC-II) and Memory for Digits on the Comprehensive Test of Phonological Processing, 2nd Edition (CTOPP-2) that met the Weschler Digit Span cutoff indicative of poor effort. Evidence of Ganser symptoms (e.g., nearly correct or approximate answers) was present on math calculation performance on the Woodcock Johnson Tests of Achievement, 4th Edition (WJTA-IV). Further, apparently deliberate markings of “X” solely on his incorrect responses on a dichotomous (yes/no) reading task also suggested deliberate feigning of low reading skills. Conclusions This case highlights the importance of effort testing in children, especially as poor effort was not apparent to the examiner, nor did there appear to be any obvious gain. Comparing data on tasks similar to already established PVTs may help expand opportunities to test effort systematically and frequently throughout a neuropsychological evaluation, and has implications for other professionals (e.g., School Psychologists, Speech Language Pathologists, etc.) who evaluate children.

Ethical Issues in Adult Cognitive Disorders

During the past few decades, there has been tremendous progress in the diagnosis and treatment of cognitive disorders. With these opportunities to advance diagnosis and care, there are new ethical and practical concerns. This chapter provides a general overview of ethical issues related to patients with diminished cognitive functioning. It describes essential concepts and issues that clinicians must know, such as treatment decision-making, limitations on independence, protection from harm, and interpretive issues surrounding effort testing. It then describes ethical issues related to clinical research, such as informed consent and assent for research participation, and considerations when conducting clinical trials. Finally, the chapter describes some issues surrounding neuroethics, such as preparing for and dealing with incidental findings, early detection of disorders, neuroenhancement, and the use of deception.