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Discriminating Among ADHD Alone,

ADHD With a Comorbid Psychological
Disorder, and Feigned ADHD in a College
Sample
a a a
Kimberly D. Williamson , Hannah L. Combs , David T. R. Berry ,
a a a
Jordan P. Harp , Lisa H. Mason & Maryanne Edmundson
a
Department of Psychology, University of Kentucky, Lexington, KY
40506, USA
Published online: 16 Sep 2014.

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To cite this article: Kimberly D. Williamson, Hannah L. Combs, David T. R. Berry, Jordan P.
Harp, Lisa H. Mason & Maryanne Edmundson (2014) Discriminating Among ADHD Alone, ADHD
With a Comorbid Psychological Disorder, and Feigned ADHD in a College Sample, The Clinical
Neuropsychologist, 28:7, 1182-1196, DOI: 10.1080/13854046.2014.956674

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 The Clinical Neuropsychologist, 2014
Vol. 28, No. 7, 1182–1196, http://dx.doi.org/10.1080/13854046.2014.956674

Discriminating Among ADHD Alone, ADHD With a

Comorbid Psychological Disorder, and Feigned ADHD in a
College Sample

Kimberly D. Williamson, Hannah L. Combs, David T. R. Berry,

Jordan P. Harp, Lisa H. Mason, and Maryanne Edmundson
Department of Psychology, University of Kentucky, Lexington, KY 40506, USA
Downloaded by [University of Connecticut] at 09:49 02 February 2015

Since the early 2000s concern has increased that college students might feign ADHD in pursuit
of academic accommodations and stimulant medication. In response, several studies have vali-
dated tests for use in differentiating feigned from genuine ADHD. Although results have gener-
ally been positive, relatively few publications have addressed the possible impact of the
presence of psychological disorders comorbid with ADHD. Because ADHD is thought to have
accompanying conditions at rates of 50% and higher, it is important to determine if the addi-
tional psychological disorders might compromise the accuracy of feigning detection measures.
The present study extended the findings of Jasinski et al. (2011) to examine the efficacy of vari-
ous measures in the context of feigned versus genuine ADHD with comorbid psychological dis-
orders in undergraduate students. Two clinical groups (ADHD only and ADHD + comorbid
psychological disorder) were contrasted with two non-clinical groups (normal controls answer-
ing honestly and normal participants feigning ADHD). Extending previous research to individu-
als with ADHD and either an anxiety or learning disorder, performance validity tests such as the
Test of Memory Malingering (TOMM), the Letter Memory Test (LMT), and the Nonverbal
Medical Symptom Validity Test (NV-MSVT) were effective in differentiating both ADHD
groups from normal participants feigning ADHD. However, the Digit Memory Test (DMT) un-
derperformed in this study, as did embedded validity indices from the Wechsler Adult Intelli-
gence Scale-IV (WAIS-IV) and Woodcock Johnson Tests of Achievement-III (WJ-III).

Keywords: ADHD; Malingering; Performance validity tests.

INTRODUCTION
Rates of diagnosed adult ADHD have increased dramatically over the past two
decades, likely in response to the growing awareness that ADHD symptoms may persist
into adulthood (Quinn, 2003). Estimates of the prevalence of adult ADHD have varied
from 2.5% (APA, 2013) to 4.4% (Kessler et al., 2006) to about 5% (Barkley, Murphy,
& Fischer, 2007) of the general adult population. Both accurate diagnosis and preva-
lence estimates have been complicated by the long-standing DSM-IV-TR requirement
that symptoms must have been present before the age of 7, as adults may have trouble
recalling and judging the extent of their childhood impairment.
Quinn (2003) suggested that faking might also contribute to the difficulty of diag-
nosing ADHD in adulthood. Malingering has been defined by the DSM-IV-TR as “the
intentional production of false or grossly exaggerated physical or psychological

Address correspondence to: David T. R. Berry, Department of Psychology, University of Kentucky,

Lexington, KY 40506, USA. E-mail: [email protected]
(Received 30 June 2014; accepted 13 August 2014)

© 2014 Taylor & Francis

 FEIGNED AND COMORBID ADHD 1183

symptoms, motivated by external incentives” (APA, 2000, p. 739). It is difficult to

determine the base rates of feigning, in part because “real world” feigners rarely con-
fess. However, it is reasonable to assume that the prevalence of faking would rise as
associated benefits increased in magnitude. In fact, feigning of ADHD is now generally
viewed as a widespread problem in cases where there is potential for secondary gain
(Harrison, 2006). Consistent with this concern, Suhr, Hammers, Dobbins-Buckland,
Zimak, and Hughes (2008) reported that 31% of consecutive referrals of young adults
for ADHD evaluations at a U.S. university failed a well-validated test of feigned
cognitive deficits, whereas Harrison and Edwards (2010) reported that about 15% of a
Canadian post-secondary sample also failed widely used tests of cognitive feigning.
In a college setting there are many potential benefits an individual may receive
upon successfully faking ADHD. These include significant academic accommodations,
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cognition- and performance-enhancing drugs, and the potential for recreational use of
stimulant medication (Harrison, 2006; Kane, 2008; McCabe, Knight, Teter, & Wechsler,
2005). Advokat, Guidry, and Martino (2011) surveyed a large sample of undergraduate
college students and reported that, among those who did not have a diagnosis of
ADHD, 43% acknowledged using prescription stimulant medications illegally. Further,
Advocat et al. found that of those surveyed who had been diagnosed with ADHD and
received prescription stimulants, 84% had been asked to share their medications with a
non-diagnosed student, and 19% had been asked how to fake ADHD. Thus, it has
grown increasingly important to identify objective methods for detecting feigning in
ADHD evaluations for college students at both the local campus and wider community
levels to prevent inappropriate accommodations and the possible dangerous misuse of
prescription stimulant medications.
Because ADHD is frequently diagnosed with a combination of clinical interview
and self-report measures, it is relatively easy for individuals to endorse symptoms that
they do not actually have. The potential ease of feigning is exacerbated by the fact that
very few self-report ADHD symptom scales are equipped with validity checks to detect
faking (Harrison, 2006; Quinn, 2003), and information on the disorder and feigning
strategies is easily available on the internet (as well illustrated by an Internet search
using the phrase “how to fake ADHD”). Therefore it has been recommended that inter-
views and self-report symptom measures should not be the only means of evaluation in
ADHD assessment (Fisher & Watkins, 2008; Quinn, 2003).
Research into feigning from the 1980s to the mid-2000s was particularly focused
on mild traumatic brain injury (mTBI), and the study of faking ADHD is still a rela-
tively new area of inquiry. With some notable exceptions, the majority of published
studies have compared ADHD groups with vs. without an incentive to feign (differen-
tial prevalence design), or contrasted normal participants asked to fake ADHD with
genuine ADHD patients who are instructed to answer honestly (simulation design). Cur-
rent findings suggest that individuals instructed to fake ADHD symptoms can easily
feign credible symptoms on self-report tests and also typically show significantly
decreased performances on neuropsychological measures as well as performance valid-
ity tests (PVTs; Booksh, Pella, Singh, & Gouvier, 2010; Harrison, Edwards, & Parker,
2007); these findings are supported in clinical samples as well (Suhr et al., 2008;
Sullivan, May, & Galbally, 2007). Evidence from the neuropsychological literature sug-
gests PVTs are well validated for detection of feigned neuropsychological disorder
(Boone, 2007; Larrabee, 2007; Sollman & Berry, 2011).
 1184 KIMBERLY D. WILLIAMSON ET AL.

Two recent simulation studies on detection of feigned ADHD used PVTs as well
as detection via indices embedded in standard neuropsychological tests. These investi-
gations compared performance on various measures between simulated ADHD malin-
gerers and a variety of control groups in college samples (Jasinski, Harp, Berry,
Shandera-Ochsner, Mason, & Ranseen, 2011; Sollman, Ranseen, & Berry, 2010).
Sollman et al. (2010) compared ADHD simulators with ADHD controls and normal
controls on a wide array of measures and found that feigners performed significantly
worse than ADHD controls on standard neuropsychological tests as well as on PVTs
and embedded validity indices. Effect sizes were robust (most ds ≥ 1.0), and very high
specificity and moderate sensitivity were found for most of the feigning measures.
In an extension of Sollman et al.’s (2010) findings, Jasinski et al. (2011) used a
modified battery to compare the test performance of normal participants and genuine
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ADHD patients answering under honest instruction with normal participants feigning
ADHD and genuine ADHD patients asked to exaggerate their symptoms. A mood dis-
order control group was included as well. Broadly speaking, results were consistent
with Sollman et al.’s (2010) findings with ds for PVTs ranging from 1.0 to 1.6.
Thus, there is growing evidence that feigned ADHD can be discriminated from
genuine ADHD using PVTs and embedded validity indices. However, one potentially
confounding variable that has not been widely studied is the extent to which comorbid
psychological diagnoses might complicate differentiation of feigned from genuine
ADHD. Most prevalence estimates suggest that half or more of the individuals who
meet diagnostic criteria for ADHD also have another psychological disorder (Barkley
et al., 2007; Cumyn, French, & Hechtman, 2009; Kessler et al., 2006; Sobanski, 2006;
Torgersen, Gjervan, & Rasmussen, 2006). Some of the most common psychological
comorbidities include anxiety and mood disorders, personality and substance use disor-
ders, and learning disorders (Cumyn et al., 2009; Torgersen et al., 2006). Because a sig-
nificant portion of individuals with ADHD are likely to have additional diagnoses, it is
crucial to gain a better understanding of how comorbid disorders might affect test
performance, particularly in the case of feigning detection measures.
To address the possible impact of ADHD + comorbid psychological disorders,
the present study used a simulation design and was conducted similarly to that of
Jasinski et al. (2011) with a few methodological changes. Comparable to the previous
study, the present study examined differences between non-clinical individuals
instructed to feign ADHD (NLF) and honest ADHD only (ADHD-O) individuals. An
additional clinical control group was comprised of individuals with ADHD + a comor-
bid psychological disorder (ADHD-CO). The ADHD-CO group included two types of
disorders commonly comorbid with ADHD: Anxiety Disorders and Learning Disorders.
This design allowed exploration of the possible impact of ADHD with co-occurring
psychological disorder on the discrimination of genuine and feigned ADHD.

METHOD
Participants
A total of 88 undergraduate students, 74 recruited through an introductory
psychology participant pool and 14 recruited by fliers placed at a disability resource
center on a university campus, enrolled in the study. Three groups were targeted for
 FEIGNED AND COMORBID ADHD 1185

inclusion in the study: individuals with a history of ADHD and no other psychological
or neurological disorder (ADHD only: ADHD-O), individuals with a history of ADHD
and a comorbid Anxiety or Learning Disorder (ADHD-CO), and normal participants
with no history of psychological or neurological disorder. Eligible individuals in the last
group were randomly assigned to either the normal feigning (NLF) group or the normal
controls responding honestly (NLH) group at a ratio of approximately 2:1. The NLH
group was smaller than the others because it served primarily as a manipulation check,
and the large effect sizes associated with simulated malingering require less power to
detect a statistically significant difference between the NLH and NLF groups. Individu-
als recruited through the participant pool were compensated with five of their required
six research credits, while participants who were recruited via flier were compensated
with $40.
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All individuals underwent an initial phone interview to determine eligibility. To

qualify for participation, normal control individuals (NLH and NLF) could not have a
history of diagnosed or suspected ADHD, learning disorders, brain injury, neurological
disorders, or psychological disorders. Individuals who were being interviewed for par-
ticipation in either of the clinical groups (ADHD-O or ADHD-CO) were asked about
the process they went through to obtain their diagnoses. It was required that ADHD
diagnoses be received from or verified by a mental health practitioner and based on
more than just self-reported symptoms and/or a brief consultation. Most individuals
reported having completed self-report questionnaires on ADHD symptoms as well as
undergoing cognitive and/or neuropsychological testing (e.g., intelligence testing, con-
tinuous performance testing). All participants with ADHD were required to have
received their diagnoses before the age of 18, and more than half of these participants
received their diagnoses by age 12. Participants with ADHD who were currently pre-
scribed stimulant medication were asked to abstain from their medication for 12 hours
prior to participating in the study.
Data from 12 participants were ultimately excluded from analysis. Six individuals
were dropped because they endorsed neurological or psychological conditions on
questionnaires completed at the time of the study that had not been revealed during the
telephone screening. Three individuals’ data were removed from analysis because they
were outliers on either the age or WRAT-4 Word Reading standard score variables. One
individual was excluded because he could not stay awake during testing, and another
individual’s data were dropped because the testing session was terminated due to
inclement weather. Finally, one individual from the NLF group was excluded because
he indicated on a post-test questionnaire that he did not give adequate effort in follow-
ing instructions. Overall, six participants from the NLF group, five participants from the
ADHD-O group, and one participant from the NLH group were excluded from analy-
ses, resulting in the following sample sizes: NLH n = 9, NLF n = 23, ADHD-O n = 22,
and ADHD-CO n = 22.
Characteristics of the participants included in the final analysis are presented in
Table 1. There were no significant differences between groups on any of these vari-
ables, including gender, age, education, race, and word-reading ability (WRAT-4). A
further analysis explored possible differences in the diagnostic characteristics of the
ADHD-O and ADHD-CO groups. There were no statistically significant differences
between these two groups for age at diagnosis, ADHD subtype, or prescription of stim-
ulant medication. However, there was a statistically significant difference in proportion
 1186 KIMBERLY D. WILLIAMSON ET AL.

Table 1. Demographic characteristics of participants included in final analyses

Group descriptives Omnibus test

Variable NLH NLF ADHD-O ADHD-CO F or χ2

n=9 n = 23 n = 22 n = 22 N = 76 p

Male (%) 44.44 56.52 50.00 31.82 2.96 .398

Age (years)
M 19.44 20.04 19.05 19.50 1.89 .193
SD 1.59 1.33 1.29 1.54
Education (years)
M 12.67 13.26 12.73 13.09 1.16 .332
SD 1.00 0.92 1.12 1.34
Repeat Grade (%) 0.00 4.35 0.00 9.09 2.82 .420
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Ethnicity (%) 7.20 .303

White 100.00 86.96 100.00 100.00
Black 0.00 8.70 0.00 0.00
Hispanic 0.00 4.35 0.00 0.00
Other 0.00 0.00 0.00 0.00
WRAT: WR St. S
M 99.44 106.04 98.55 99.32 2.19 .097
SD 16.08 8.21 8.18 13.47

NLH = Normal Honest; NLF = Normal Feigning; ADHD-O = ADHD Only; ADHD-CO = Comorbid
ADHD; M = Mean; SD = Standard Deviation; WRAT: WR St.S = Wide Range Achievement Test-4 (WRAT-4)
Word Reading Standard Score.

receiving current academic accommodations (ADHD-O 27.3%; ADHD-CO 59.1%;

χ2 = 5.4 (1), p < .02). Within the ADHD-CO group, of the nine individuals reportedly
diagnosed with LDs, six stated that they had a Reading disability, two a Writing disabil-
ity and one a Combined disability. The remaining 13 participants in the ADHD-CO
group reported having been diagnosed with an Anxiety Disorder in addition to ADHD.

Procedure
Two researchers (RA1 and RA2) were present for each testing. RA1 conducted
the pre-test session which included completing a background/demographics question-
naire, confirming that individuals with ADHD had abstained from their stimulant
medication, completing the IRB informed consent process, administering the pre-test
measures under standard instructions, and presenting experimental instructions. All
participants were told by RA1 not to reveal their instructions to RA2.
Honest participants (NLH, ADHD-O, and ADHD-CO) were instructed to give
their best effort throughout the session. Feigning participants (NLF) were asked to per-
form on the tests in a way that would ensure that they received an ADHD diagnosis.
NLF participants were cautioned not to be so obvious that they would be detected by
RA2. They were offered a “conditional” $25 incentive should they successfully fake
ADHD. In fact, all participants in the NLF group received this $25 in the debriefing
session, per IRB protocol. NLF participants were provided a scenario to increase their
motivation to feign believably:
You have a friend on campus who has just been diagnosed with ADHD. She is
prescribed a stimulant drug (like Ritalin or Adderall) that makes her concentrate better
 FEIGNED AND COMORBID ADHD 1187

and stay awake more easily. Studying becomes so much easier for her that it takes
almost no time at all. On top of that, the university gives her extra time to complete
exams and other assignments because she has ADHD. Schoolwork becomes so easy for
your friend that it seems like she is able to socialize and have fun whenever she wants.
She tells you that all she had to do was take a few tests to receive her diagnosis. You
feel you could really use some extra time on exams and assignments, and it would be
great to have some medication to help you study faster, so you decide you will try to
get a diagnosis, too. You search the internet for information on ADHD, and you make
an appointment for testing.
NLF participants were also given a four-page packet detailing the most common
ADHD symptoms and characteristics, accessible via the Internet, to review. The sce-
nario and information were taken from the study by Jasinski et al. (2011). Following
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review of the materials, RA1 administered an “Instruction Check” handout which

required participants to write out their instructions from memory, list three characteris-
tics of individuals with ADHD, and provide three strategies they planned to utilize to
convince the tests that they had ADHD. After participants had satisfactorily completed
this worksheet and any questions had been answered, RA2 replaced RA1 and adminis-
tered the test battery in counterbalanced order. Following completion of the test battery,
RA2 left and RA1 returned for the debriefing process. NLF participants were required
to complete a post-test questionnaire on which they were asked to write their instruc-
tions from memory. They were also required to rate their performance on various
5-point Likert scales regarding understanding of their instructions, as well as perceived
effort, success, difficulty, and motivation. As previously noted, one participant in the
NLF group did not meet the required minimum rating of at least 4 on the 5 point Likert
scale items and was dropped from analysis.

Test Measures
Self-report inventories. All participants completed the Adult ADHD Rating
Scale (ASRS; Kessler et al., 2005) as well as the Beck Anxiety Inventory (BAI: Beck
& Steer, 1993) under standard instructions to characterize the groups prior to the
experimental manipulation. In contrast, the Barkley Adult ADHD Rating Scale-IV, a
self-report measure of ADHD symptoms in adults, (BAARS-IV; Barkley, 2011) was
completed by all participants under experimental instructions and was intended to
explore the effects of the experimental manipulation.

Neuropsychological measures. The Wide Range Achievement Test-4

(WRAT-4; Wilkinson & Robertson, 2006) Word Reading, Sentence Completion, and
Spelling subtests were given under standard instructions to characterize the samples. In
contrast, under experimental instructions (honest or feign ADHD), all participants were
administered the Computerized Test of Information Processing, a continuous perfor-
mance test, (CTIP; Tombaugh & Rees, 2000), the Reading Fluency subtest of the
Woodcock-Johnson-III Test of Achievement (WJ-III; Mather & Woodcock, 2001), and
the Coding (C), Symbol Search (SS), and Digit Span (DS) subtests from the Wechsler
Adult Intelligence Scale-IV (WAIS-IV; Wechsler, 2008). These instruments were
included in the test battery both to ascertain the utility of embedded indices for differen-
tiating the NLF, ADHD-O and ADHD-CO groups and to bolster ecological validity.
 1188 KIMBERLY D. WILLIAMSON ET AL.

In regard to the latter point, there were a total of five dedicated PVTs (see below), eight
standard neuropsychological tests, and one self-report symptom inventory in the
experimental battery.

Performance validity tests and embedded validity indices. Various per-

formance validity tests (PVTs) were administered under instruction set, with the goal of
replicating and extending the findings of Sollman et al. (2010) and Jasinski et al.
(2011). Among those PVTs were the Test of Memory Malingering (TOMM; Tombaugh,
1996), the Digit Memory Test (DMT; Hiscock & Hiscock, 1989), the Letter Memory
Test (LMT; Inman et al., 1998), the Nonverbal Medical Symptom Validity Test
(NV-MSVT; Green, 2008), and the b Test (Boone et al., 2000). Embedded validity
indices, which had previously been used in the Jasinski et al. (2011) paper, included
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Reliable Digit Span and Processing Speed Index from the WAIS-IV as well as the
Reading Fluency score from the WJ-III. As the cutting score for the Reading Fluency
score from the WJ-III had been described in Age Equivalent Scaled Scores by Jasinski
et al. (2011), this metric was used in the present paper as well.

Data analysis
Due to widespread skewness, kurtosis, and heterogeneity of variance in the data,
non-parametric statistics were used for the main analyses, including omnibus tests using
Kruskal-Wallis one-way ANOVA, with Mann-Whitney U follow-up contrasts. In order
to limit type I error, alpha was held at .01 for all omnibus tests. Effect sizes were
reported using Cohen’s d.

RESULTS
The NLH group was compared to the NLF group on the self-report BAARS-IV
and the performance-based CTIP to evaluate whether the experimental manipulation
was effective. A subset of the findings from the BAARS-IV and CTIP results is pre-
sented in Table 2. Considering the BAARS-IV, raw scores represent self-reported fre-
quency of symptoms and the symptom count variable represents severity of symptoms.
The NLF group exhibited significantly higher symptom endorsement than the NLH
group on all BAARS-IV variables. Further, the NLF group results were not significantly
different from the clinical groups on all but one of these variables, suggesting fairly
effective feigning. It is also worth noting that the NLF groups tended to have more
extreme scores than genuine ADHD groups on these variables. Finally, the BAARS-IV
scales were significantly higher for the two ADHD groups than for the NLH group,
supporting the validity of the self-reported ADHD diagnoses. Turning to the CTIP data,
it can be seen that the NLF group scored significantly worse on all three variables, with
no significant differences between the two ADHD groups. Overall, these results suggest
that the malingering instructions induced the intended response set and did so in an
apparently realistic way. Having established the integrity of the experimental manipula-
tion, NLH data were not included in further analyses to avoid inflating the apparent
effectiveness of the validity indices.
 FEIGNED AND COMORBID ADHD 1189

Table 2. BAARS-IV and CTIP: Mean group differences

Omnibus test
Group descriptives (N = 76)

ADHD-O ADHD-CO
NLH n = 9 NLF n = 23 n = 22 n = 22
M (SD) M (SD) M (SD) M (SD) K p

Barkley’s Adult ADHD

Rating Scale-IV
Inattention Raw Score 14.11 (4.28)a 23.39 (4.74)b 21.50 (4.73)b 21.19 (6.23)b 19.13 .001**
Hyperactivity Raw 7.44 (2.40)a 13.78 (2.75)b 11.05 (3.54) c 11.71 (2.47)bc 21.90 .001**
Score
Impulsivity Raw Score 5.67 (1.94)a 10.48 (2.31)b 10.00 (3.92)b 9.29 (3.15)b 15.03 .002*
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Total ADHD Raw 27.22 (7.68)a 46.04 (12.79)b 42.55 (9.51)b 42.19 (9.91)b 18.02 .001**
Score
Inattention Symptom 0.67 (1.32)a 5.30 (2.30)b 3.77 (2.45)b 3.57 (2.91)b 20.37 .001**
Count
Hyperactivity/ 0.89 (1.36)a 5.17 (2.23)b 3.86 (2.80)b 3.67 (2.11)b 18.15 .001**
Impulsivity Symptom
Count
Total ADHD Symptom 1.44 (2.55)a 10.48 (4.28)b 7.64 (4.18)b 7.24 (4.27)b 21.88 .001**
Count
Computerized Test of
Information Processing
Simple RT Median RT .29 (.03)a .50 (.22)b .30 (.004)ac .32 (.05)ac 21.33 .001**
Choice RT Median RT .51 (.07)a .90 (.28)b .56 (.14)ac .60 (.22)ac 29.86 .001**
Semantic Choice RT .78 (.15)a 7.36 (28.9)b .83 (.25)ac .90 (.22)ac 24.05 .001**
Median RT

These values reflect the performance of participants under experimental manipulation. NLH = Normal
Honest; NLF = Normal Feigning; ADHD-O = ADHD Only; ADHD-CO = Comorbid ADHD; K = Kruskal-
Wallis Chi-Square value; M = Mean; SD = Standard Deviation; RT = Reaction Time.
abc
Within each row, columns with different letters are statistically significantly (p < .01) different from
each other using Mann-Whitney U follow-up contrasts.
* = significant at p < .01 level; ** = significant at p < .001 level.

Table 3 displays the results from the omnibus test and follow-up contrasts for the
PVTs and embedded validity indices. The NLF group demonstrated significantly worse
performances than ADHD-O and ADHD-CO on all of the PVTs, with the exception of
the Efficiency score from the b-test, where the NLFs were only significantly different
from the ADHD-O group. Turning to the embedded validity indices, Reliable Digit
Span did not show a significant difference across the groups. For both the WAIS-IV
PSI variable and the WJ-III Reading Fluency variable, the NLF group performed
significantly worse than the ADHD-O group but not significantly different from the
ADHD-CO group. Additionally, the ADHD-O and ADHD-CO group were significantly
different on the WJ-III Reading Fluency variable, with the latter group producing lower
scores. These results raise questions about the effectiveness of the three embedded
indices.
The effect size data in the rightmost three columns in Table 3 show the typi-
cal robust values on PVTs when the NLF group is compared to the ADHD-O and
 1190 KIMBERLY D. WILLIAMSON ET AL.

Table 3. Neurocognitive feigning test results by group on dedicated and embedded effort tests

Group descriptives Cohen’s d

ADHD-
NLF ADHD- CO NLF vs. NLF vs. ADHD-O
n=23 O n=22 n=22 K ADHD- ADHD- vs. ADHD-
M (SD) M (SD) M (SD) N = 67 O CO CO

Test of Memory
Malingering
Trial 1% Correct 80.17 94.55 92.27 20.81** –1.41 –1.21 0.29
(12.04) (8.38) (7.81)
Trial 2% Correct 89.48 99.64 99.82 32.02** –1.23 –1.25 –0.20
(11.76) (1.00) (0.85)
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Retention Trial % 88.96 99.45 99.36 30.31** –1.31 –1.31 0.08

Correct (11.33) (1.41) (0.95)
Digit Memory Test % 95.28 99.37 99.50 18.82** –0.83 –0.85 –0.07
Correct (6.83) (1.90) (1.85)
Letter Memory Test % 93.05 98.89 99.30 13.14* –1.02 –1.10 –0.26
Correct (8.04) (1.78) (1.43)
b Test
E-Score 180.03 45.06 84.22 12.53* 1.07 0.66 –0.52
(179.27) (17.98) (107.00)ᵇ
Nonverbal Medical
Symptom Validity Test
Criterion A1 90.18 96.82 96.82 17.10** –1.28 –1.28 0.00
(6.70) (3.20) (3.26)
Criterion A2 85.65 95.23 95.51 17.92** –1.30 –1.34 –0.06
(9.45) (4.80) (4.72)
Wechsler Adult
Intelligence Scale-IV
Reliable Digit Span 8.87 9.32 9.27 1.05 –0.30 –0.27 0.03
(1.42) (1.62) (1.58)
Processing Speed 91.00 106.82 98.23 11.09* –0.99 –0.58 0.67
Index (15.48) (16.37) (9.45)
Woodcock-Johnson-III
Tests of Achievement
Reading Fluency – 15.25 20.42 17.17 14.83* –1.33 –0.46 0.91
Age-Equivalent Scaled (4.53) (3.28) (3.84)
Score

These values reflect the performance of participants under experimental manipulation. Kruskal-Wallis non-
parametric test (df = 2) was used due to violations of the assumptions of normality. Within each row, moving
from left to right, columns with different letters are statistically significantly (p < .01) different from each
other using Mann-Whitney U follow-up contrasts. NLF = Normal Feigning; ADHD-O = ADHD Only;
ADHD-CO = Comorbid ADHD. K = Kruskal-Wallis Chi-Square value; M = Mean; SD = Standard Deviation;
Med RT = Median Reaction Time.
* = significant at p < .01 level; ** = significant at p < .001 level.

ADHD-CO groups. In fact, the median absolute values of the effect sizes for these
comparisons are 1.25 and 1.23 for the ADHD-O and ADHD-CO groups, respec-
tively. Of further interest for present purposes are the effect sizes for the ADHD-O
vs. ADHD-CO contrast, which had a median absolute value of .14. These results
 FEIGNED AND COMORBID ADHD 1191

suggest that the feigning response set is a much more powerful determinant of
PVT performance than the comorbid disorders studied here.
Effect sizes from the embedded validity indices are more complex. First, Reliable
Digit Span from the WAIS-IV showed no statistically significant effect. The WAIS-IV
Processing Speed Index and the W-J-III Reading Fluency Test both showed strong
effect sizes for the NLF vs. ADHD-O contrast, but were substantially attenuated for the
NLF vs. ADHD-CO contrasts. The moderate to strong effect sizes in the contrast of
ADHD-O and ADHD-CO, in favor of the former, once again raise questions about the
performance of the embedded indices in this study.
For those measures exhibiting significant between group differences as indicated
in Table 3, effort test utility indicators were examined to provide information about use-
fulness in a clinical setting. These test-operating characteristics are displayed for recom-
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mended cut scores in Table 4. Published cut scores were not available for the WAIS-IV
PSI, and WJ-III RF A-E variables for detecting feigning; therefore, the high specificity
optimal cut scores derived in Jasinski et al. (2011) were used for the purpose of compari-
son. Considering the PVT data, these operating characteristics are fairly typical for

Table 4. Effort test operating characteristics for dedicated and embedded effort tests

BR (.25)
Sensitivity to Specificity for Specificity for
NLF ADHD-O ADHD-CO PPP NPP

TOMM
Trial 2% Correct .391 1.00 1.00 1.00 .831
Retention Trial % .391 1.00 1.00 1.00 .831
Correct
TOMM Overall .522 1.00 1.00 1.00 .863
DMT (%TOT < 90) .174 1.00 1.00 1.00 .784
LMT (%TOT < 93) .391 1.00 1.00 1.00 .831
b test (E-Score ≥ 120) .364 1.00 .857 .561 .815
NV-MSVT
Criterion A1 (≤ 90) .435 .955 .955 .718 .834
Criterion A2 (< 88) .478 .909 .909 .626 .839
NV-MSVT Overall .478 .909 .909 .626 .839
WAIS-IV
PSI (< 97)a .652 .727 .591 .404 .854
WJ III RF
A-E (< 16)a .478 .909 .500 .394 .813

PPP = Positive Predictive Power; NPP = Negative Predictive Power; NLF = Normal Feigning; ADHD-O =
ADHD Only; ADHD-CO = Comorbid ADHD; TOMM = Test of Memory Malingering; TOMM Overall =
raw score <45 on either or both Trial 2 and Retention Trial; DMT %TOT = Digit Memory Test Total percent
correct; LMT %TOT = Letter Memory Test Total percent correct; NV-MSVT = Non-Verbal Medical Symptom
Validity Test; NV-MSVT Overall = failure on either or both Criterion A1 and Criterion A2; CTIP = Comput-
erized Test of Information Processing; SRT Med RT = Simple Reaction Time median reaction time; CRT Med
RT = Choice Reaction Time median reaction time; SCRT Med RT = Semantic Choice Reaction Time median
reaction time; WAIS-IV = Wechsler Adult Intelligence Scale – Fourth Edition; PSI = Processing Speed Index;
WJ III RF= Woodcock-Johnson III Tests of Achievement Reading Fluency; A-E = Age-Equivalent Scale
Score.
ᵃ = cut score derived from Jasinski et al. (2011) high-specificity optimal cut scores.
 1192 KIMBERLY D. WILLIAMSON ET AL.

Table 5. Utility indicators for failure on multiple effort tests

Number of PVTs Sensitivity to Specificity for Specificity for Hit rate

failed NLF ADHD-O ADHD-CO (.25)

≥1 .870 .909 .864 .885

≥2 .478 1.00 .909 .836
≥3 .348 1.00 1.00 .835
≥4 .174 1.00 1.00 .795
≥5 .130 1.00 1.00 .783

Measures in the analysis for overall tests failed included TOMM Overall, LMT total percent correct, DMT
total percent correct, NV-MSVT Overall, b Test E-Score. SN = Sensitivity; SP = Specificity; HR(50) = Overall
Hit Rate based on estimated BR = .50; NLF = Normal Feigning; ADHD = ADHD Only; ADHD-CO =
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Comorbid ADHD.

results from feigning studies, in that high to very high specificity values at recommended
cutting scores are found, accompanied by moderate sensitivity rates. An exception to the
PVT pattern is seen for the DMT, which had low sensitivity in this study. Additionally,
the two remaining embedded validity indices had unacceptably low specificity rates in
the ADHD-CO group (Reliable Digit Span did not produce statistically significant
differences between groups and was excluded from classification analyses).
Positive and negative predictive powers are also displayed in Table 4, calculated
using a hypothetical base rate of .25. The TOMM, LMT, and DMT displayed excellent
PPP (1.00). More modest PPP values were seen for the remaining variables, with the
two embedded indices particularly weak. NPP values were generally moderately high
for all of these indices.
Because most authorities on detection of feigning recommend use of multiple
PVTs in high-stakes evaluations (Boone, 2007; Larrabee, 2007), the performance of
combinations of these tests was explored. Given the relatively poor performance of the
embedded validity indicators in analyses to this point, they were excluded from these
calculations. Table 5 shows sensitivity and specificity values for requiring that various
numbers of PVTs be failed to classify a participant as feigning. As can be seen, requir-
ing that two or more tests be failed to detect feigning had robust specificities of 1.00
and .909 for the ADHD-O and ADHD-CO groups, respectively. However, at this
cut-score, sensitivity was a more modest .478.

DISCUSSION
Concern that college students might feign ADHD in order to obtain academic
accommodations and access to prescription stimulants has grown since the early 2000s
(Quinn, 2003). This has spurred exploration and validation of procedures to detect this
phenomenon. In general, performance validity tests (PVTs), originally developed to
detect feigned neuropsychological impairment in other populations, have proved fairly
effective at detecting malingered ADHD. One question in this area that has not yet been
extensively addressed is the potential impact of comorbid disorders, common in those
with ADHD diagnoses, on the accuracy of PVTs and related procedures for identifying
feigned ADHD.
 FEIGNED AND COMORBID ADHD 1193

The present study began to address this issue by evaluating the effect of psycho-
logical disorders comorbid with ADHD on detection of feigned ADHD using PVTs.
Results suggested that several well-validated PVTs are fairly effective in discriminating
simulated ADHD from genuine ADHD alone as well as from ADHD with selected
comorbid psychological disorders. Consistent with other reports in the feigning detec-
tion literature, failure of two or more of the best performing PVTs in this study had a
near 100% accuracy rate in predicting presence of malingered ADHD. In contrast, the
validity indices embedded in standard neuropsychological tests did not perform very
well in this investigation.
In light of the heavy reliance on self-reported diagnoses in forming the groups,
additional analyses were conducted to evaluate the integrity of the Anxiety (ANX;
n = 13) and LD (LD; n = 9) subgroups of the ADHD-CO sample. Under standard
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instructions, the NLF group scored 5.8 (SD = 7.3) on the BAI whereas the ANX
subgroup scored 16.8 (SD = 15.0), which was a statistically significant difference,
t(34) = –2.4), p < .05. Also under standard instructions, on the WRAT-4 Word Reading
Subtest, the NLF group scored 106.0 (SD = 8.2) whereas the LD subgroups scored 96.4
(SD = 12.0), which was also a statistically significant difference, t(30) = 2.6; p < .01.
Similar results were found for the WRAT-4 Sentence Completion and Spelling subtests.
Finally, as noted earlier, the two ADHD groups scored significantly higher than the
NLH group under standard instructions on all indices from the BAARS. Although these
analyses do not provide gold standard verification of the diagnoses included here, they
are consistent with expected differences across the groups.
The relatively poor performance of the embedded indices studied here (WAIS-IV
Reliable Digit Span and Processing Speed Index as well as WJ-III Reading Fluency)
was surprising. Indices derived from Digit Span have typically performed well in other
populations (Jasinski et al., 2011), and the Digit Span results are possibly idiosyncratic
to the present samples. In the case of the PSI and WJ-III- RF, sensitivity values were
comparable to those of the dedicated PVTs. However, specificity values were poor.
Broadly similar findings for decreased psychomotor speed and lower reading scores
have been reported for individuals with ADHD and comorbid Reading Disorder (Katz,
Brown, Roth, & Beers, 2011) and depression (Larochette, Harrison, Rosenblum &
Bowie, 2011), which might explain the findings here.
Taken together with other reports in the literature to date, these results suggest
that clinicians evaluating college-aged individuals claiming ADHD in order to seek aca-
demic accommodations and stimulant medications have several useful tools for discrim-
inating feigned from genuine ADHD, even in the presence of comorbid anxiety or LD
diagnoses. It is recommended that clinicians conducting assessments in these circum-
stances include two or more well-validated PVTs in such evaluations. Most dedicated
(not embedded) PVTs included in the present study performed fairly well and could be
considered for clinical practice. It is also interesting to note that the problem of poten-
tially feigned ADHD in pursuit of academic accommodations has now reached into pro-
fessional education. Jasinski and Ranseen (2011) review this area and note that is not
unusual for law students to first request an ADHD evaluation following failure of initial
law school exams or when confronting the bar examination. In particularly high-stakes
evaluations such as accommodations for professional school students, it appears to be
imperative to utilize PVTs.
 1194 KIMBERLY D. WILLIAMSON ET AL.

Limitations of the present study include small groups, relatively narrow

demographic variability, the inherent nature of simulation studies, failure to assess for
substance abuse, lack of data on IQ equivalence across groups, the absence of indepen-
dent confirmation of ADHD diagnoses, and the inclusion of only two of many possible
conditions comorbid with ADHD. Despite these caveats, the finding that the NLF group
produced realistic ADHD patterns on both a self-report symptom checklist and a contin-
uous performance test emphasizes the ease with which ADHD may be feigned as well
as the need to use PVTs to address the validity of claimed ADHD symptoms.

AUTHOR NOTES
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Kimberly D. Williamson, Hannah L. Combs, David T. R. Berry, Jordan P. Harp,

Lisa H. Mason, and Maryanne Edmundson, Department of Psychology, University of
Kentucky.
This manuscript is based on a master’s thesis submitted by Kimberly D.
Williamson in partial fulfillment of the requirements for a master’s degree in clinical
psychology at the University of Kentucky.
David T. R. Berry holds the copyright to the Letter Memory Test. All proceeds
from the Letter Memory Test are donated to the Harris Psychological Services Center at
the University of Kentucky.

REFERENCES

Advocat, C. D., Guidry, D., & Martino, L. (2011). Licit and illicit use of medications for Atten-
tion-Deficit Hyperactivity in undergraduate college students. Journal of American College
Health, 56, 601–606.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders,
(4th ed., revised). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders,
(5th ed., revised). Arlington, VA: Author.
Barkley, R. A. (2011). Barkley Adult ADHD Rating Scale-IV (BAARS-IV). New York, NY:
Guilford.
Barkley, R. A., Murphy, K. R., & Fischer, M. (2007). ADHD in adults: What the science says.
New York, NY: The Guilford Press.
Beck, A. T., & Steer, R. A. (1993). Beck Anxiety Inventory manual. San Antonio, TX: Psycholog-
ical Corporation.
Booksh, R. L., Pella, R. D., Singh, A. N., & Gouvier, W. D. (2010). Ability of college students
to simulate ADHD on objective measures of attention. Journal of Attention Disorders, 13,
325–338.
Boone, K. B. (2007). Assessment of feigned cognitive impairment: A neuropsychological perspec-
tive. New York, NY: The Guilford Press.
Boone, K. B., Lu, P., Sherman, D., Palmer, B., Back, C., Shamieh, E., … Berman, N. G. (2000).
Validation of a new technique to detect malingering of cognitive symptoms: The b Test.
Archives of Clinical Neuropsychology, 15, 227–241.
Cumyn, L., French, L., & Hechtman, L. (2009). Comorbidity in adults with attention-deficit
hyperactivity disorder. The Canadian Journal of Psychiatry, 54, 673–683.
 FEIGNED AND COMORBID ADHD 1195

Fisher, A. B., & Watkins, M. W. (2008). ADHD rating scales’ susceptibility to faking in a college
student sample. Journal of Postsecondary Education and Disability, 20, 81–92.
Green, P. (2008). Green’s Nonverbal Medical Performance validity test (NV-MSVT) for Microsoft
Windows: User’s manual 1.0. Edmonton: Green’s Publishing.
Harrison, A. G. (2006). Adults faking ADHD: You must be kidding! The ADHD Report, 14, 1–5.
Harrison, A. G., & Edwards, M. J. (2010). Symptom exaggeration in post-secondary students:
Preliminary base rates in a Canadian sample. Applied Neuropsychology, 17, 135–143.
Harrison, A. G., Edwards, M. J., & Parker, K. C. H. (2007). Identifying students faking ADHD:
Preliminary findings and strategies for detection. Archives of Clinical Neuropsychology, 22,
577–588.
Hiscock, M., & Hiscock, C. K. (1989). Refining the forced-choice method for the detection of
malingering. Journal of Clinical and Experimental Neuropsychology, 11, 967–974.
Inman, T. H., Vickery, C. D., Berry, D. T. R., Lamb, D. G., Edwards, C. L., & Smith, G. T.
Downloaded by [University of Connecticut] at 09:49 02 February 2015

(1998). Development and initial validation of a new procedure for evaluating adequacy of
effort given during neuropsychological testing: The Letter Memory Test. Psychological
Assessment, 10, 128–149.
Jasinski, L. J., Harp, J. P., Berry, D. T. R., Shandera-Ochsner, A. L., Mason, L. H., & Ranseen, J.
D. (2011). Using Performance validity tests to detect malingered ADHD in college students.
The Clinical Neuropsychologist, 25, 1415–1428.
Jasinski, L. J., & Ranseen, J. D. (2011). Malingered ADHD evaluations: A further complication
for accommodations reviews. The Bar Examiner, December, 6–16.
Kane, S. T. (2008). Minimizing malingering and poor effort in the LD/ADHD evaluation process.
The ADHD Report, 16, 5–9.
Katz, L. J., Brown, F. C., Roth, R. M., & Beers, S. R. (2011). Processing speed and working
memory performance in those with both ADHD and a reading disorder compared with those
with ADHD alone. Archives of Clinical Neuropsychology, 26, 423–433.
Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E., … Walters, E. (2005).
The World Health Organization Adult ADHD Self-Report Rating Scale (ASRS): A short
screening scale for use in the general population. Psychological Medicine, 35, 245–256.
Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Connors, C. K. Demler, O., … Zaslavsky, A.
(2006). The prevalence and correlates of Adult ADHD in the United States: Results from the
National Comorbidity Survey Replication. American Journal of Psychiatry, 163, 716–723.
Larochette, A.-C., Harrison, A. G., Rosenblum, Y., & Bowie, C. R. (2011). Additive neurocogni-
tive deficits in adults with attention-deficit/hyperactivity disorder and depressive symptoms.
Archives of Clinical Neuropsychology, 26, 385–395.
Larrabee, G. J. (2007). Assessment of feigned neuropsychological deficits. New York, NY: Oxford
Press.
Mather, N., & Woodcock, R. W. (2001). Examiner’s manual: Woodcock-Johnson III Test of
Achievement. Itasca, IL: Riverside.
McCabe, S. E., Knight, J., Teter, C. J., & Wechsler, H. (2005). Non-medical use of prescription
stimulants among US college students: Prevalence and correlates from a national survey.
Addiction, 99, 96–106.
Quinn, C. A. (2003). Detection of malingering in assessment of adult ADHD. Archives of Clinical
Neuropsychology, 18, 379–395.
Sobanski, E. (2006). Psychiatric comorbidity in adults with attention-deficit/hyperactivity disorder
(ADHD). European Archives of Psychiatry and Clinical Neuroscience, Sep; 256 Suppl 1,
i26–31.
Sollman, M. J., & Berry, D. T. R. (2011). Detection of inadequate effort on neuropsychological
testing: A meta-analytic update and extension. Archives of Clinical Neuropsychology, 26,
774–789.
 1196 KIMBERLY D. WILLIAMSON ET AL.

Sollman, M. J., Ranseen, J. D., & Berry, D. T. R. (2010). Detection of feigned ADHD in college
students. Psychological Assessment, 22, 325–335.
Suhr, J. A., Hammers, D., Dobbins-Buckland, K., Zimak, E., & Hughes, C. (2008). The relation-
ship of malingering test failure to self-reported symptoms and neuropsychological findings
in adults referred for ADHD evaluation. Archives of Clinical Neuropsychology, 23, 521–530.
Sullivan, B. K., May, K., & Galbally, L. (2007). Symptom exaggeration by college adults in
attention-deficit hyperactivity disorder and learning disorder assessments. Applied Neuropsy-
chology, 14, 189–207.
Tombaugh, T. N. (1996). Test of Memory Malingering: TOMM. North Tonawanda, NY:
Multi-Health Systems Inc.
Tombaugh, T. N., & Rees, L. (2000). Manual for the Computerized Tests of Information Process-
ing (CTIP). Ottawa: Carleton University Press.
Torgersen, T., Gjervan, B., & Rasmussen, K. (2006). ADHD in adults: A study of clinical
Downloaded by [University of Connecticut] at 09:49 02 February 2015

characteristics, impairment and comorbidity. Nord Journal of Psychiatry, 60, 38–43.

Wechsler, D. (2008). Manual for the Wechsler Adult Intelligence Scale (4th ed.). San Antonio,
TX: The Psychological Corporation.
Wilkinson, G. S., & Robertson, G. J. (2006). Wide Range Achievement Test (4th ed.). Lutz, FL:
Psychological Assessment Resources.