Assessment of Effort and Validity in Neuropsychological Testing: The Importance of Determining Symptom Credibility

July 17, 2013; 1-2:30 p.m. (ET)


One of the issues that providers face when treating someone with TBI is determining the credibility of the patient’s symptoms. Unfortunately, there are some service members with mild TBI who feign or exaggerate symptoms. This poses a number of challenges, including how to determine if a patient is credible, how to reconcile differences in clinical standards, how to overcome disagreements between clinicians and how to deal with a potentially unpleasant interaction with the patient.

The goal of this presentation is to educate health care providers about the standard of practice for symptom validity testing. We will illustrate the importance of a data-driven, objective approach to assess the credibility of symptoms. We will use several case examples from a concussion care clinic to show these principles in practice. 

Learning Objectives

  • Understand the difficulty of evaluating the credibility of a patient’s presentation
  • See the value of a data-driven, scientific approach to assessing credibility of symptom reports
  • Learn the standard of care for assessment of credibility, especially in neuropsychological evaluations
  • Understand what key words or sections should be included in a neuropsychological evaluation regarding assessment of effort and symptom credibility
  • Obtain examples of these principles in practice in a military treatment facility


Wesley R. Cole, Ph.D.
Senior Scientific Director, DVBIC Neuropsychologist, Department of Brain Injury Medicine Womack Army Medical Center, Fort Bragg, N.C. Wesley R. Cole received a bachelor’s degree in psychology from James Madison University. He earned a master’s degree and doctorate in clinical psychology from the University of South Carolina. After moving to Baltimore, Cole completed predoctoral internships and postdoctoral fellowships in pediatric psychology and neuropsychology at the Kennedy Krieger Institute, an affiliate of the Johns Hopkins School of Medicine. He worked for a year at the Kennedy Krieger Institute’s Department of Neuropsychology. In 2008, he accepted a job at the Womack Army Medical Center’s Concussion Care Clinic. Looking to expand his roles into research activities, he joined the DVBIC at Fort Bragg in 2009. He continues to divide his time, conducting neuropsychological assessments in the Concussion Care Clinic and overseeing DVBIC research at Fort Bragg.
Robert Stegman, Ph.D.
Clinical Neuropsychologist, Department of Brain Injury Medicine Womack Army Medical Center, Fort Bragg, N.C. Robert Stegman was on active duty in the enlisted ranks from 1964 through 1972, mostly in Southwest Asia. He earned a bachelor’s degree in psychology from Purdue University and received his master’s and doctoral degrees from the University of Missouri – Columbia. Stegman completed his internship at the Indiana University School of Medicine where he developed a professional interest in neuropsychology. He worked for the Department of Veterans Affairs (VA) from 1980 through 2008. His clinical duties focused on posttraumatic stress disorder and neuropsychology and included thousands of disability/forensic assessments. Stegman was the Accreditation Site Visitor for the American Psychological Association. He was active in the development of competencies for psychologists, and he set the course of training for the next decade. Stegman also was the chairperson of the Doctoral Membership Review Committee for the Association of Psychology Postdoctoral and Internship Centers. He left the VA and resigned from national professional activities to work in the Department of Brain Injury Medicine at Womack Army Medical Center.


Douglas B. Cooper, Ph.D., ABPP-CN
Research Neuropsychologist, DVBIC San Antonio Military Medical Center, Texas Douglas B. Cooper is board certified in clinical neuropsychology and earned his Ph.D. in clinical psychology at the University of Texas Southwestern Medical Center. He completed his postdoctoral fellowship in neuropsychology at Baylor College of Medicine and TIRR Rehabilitation Hospital. He is a co-investigator on a prospective randomized controlled trial of cognitive rehabilitation for U.S. military personnel with a history of mild TBIs. His primary research interests are the evaluation and treatment of mild TBI and co-occurring psychiatric conditions. Cooper has served as a neuropsychological subject matter expert on panels for the Department of Defense (DoD), Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, the Institute of Medicine and the Veterans Health Care System. He was a primary author of the VA/DoD Clinical Practice Guidelines for the Management of Concussion/mild TBI. In addition to his work with DVBIC, he has a private practice focused on rehabilitation and forensic neuropsychology.

Continuing Education

Registration opens July 8. Those desiring CE credit must have registered for the webinar by July 14, 11:59 p.m.

DVBIC’s awarding of continuing education (CE) credit is limited in scope to health care providers who actively provide psychological health and TBI care to U.S. active-duty service members, reservists, National Guardsmen, military veterans and/or their families.

Contracted companies are responsible for their employee development and training. Contractors should review their respective scope of work (SOW) or personnel qualification guidelines to ensure they meet minimum requirements. The authority for training of contractors is at the discretion of the chief contracting official. Currently, only those contractors with SOWs or with commensurate contract language are permitted in this training.

Additional Resources

  1. Boone, K. B. (2007). Assessment of Feigned Cognitive Impairment. New York: The Guilford Press.
  2. Bush, S., Ruff, R., Troster, A., Barth, J., Koffler, S., Pliskin, N. et al (2005).  NAN position paper: Symptom validity assessment: Practice issues and medical necessity.  Archives of Clinical Neuropsychology, 20, 419-426. 
  3. Carone, D. A., Iverson, G. L., & Bush, S. S. (2010). A model to approaching and providing feedback to patients regarding invalid test performance in clinical neuropsychological evaluations. The Clinical Neuropsychologist, 24(5), 759-778.
  4. Heilbronner, R. L., Sweet, J. J., Morgan, J. E., Larrabee, G. J., Millis, S. R. & Conference Participants.  (2009). American Academy of Clinical Neuropsychology consensus conference statement on the neuropsychological assessment of effort, response bias, and malingering.  The Clinical Neuropsychologist, 12, 1093-1129.
  5. Imwinkelreid, E. J. (1993). The Daubert Decision on the Admissability of Scientific Evidence: The Supreme Court Chooses the Right Piece for All the Evidentiary Puzzles.  Journal of Civil Rights and Economic Development, 9, 1-32.
  6. Larrabee, G. J. (2002).  Detection of malingering using atypical performance patterns of standard neuropsychological tests.  The Clinical Neuropsychologist, 17, 410-425. 
  7. Larrabee, G. J. (2008). Aggregation across multiple indicators improves the detection of malingering: Relationship to likelihood ratios. The Clinical Neuropsychologist, 22(4), 666-679.
  8. Larrabee, G. J. (June 28, 2012). Performance validity, symptom validity, and malingering. Talk presented at Womack Army Medical Center, Fort Bragg.
  9. Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tadnel, D. (2012). Neuropsychological Assessment, Fifth Edition. New York: Oxford University Press.
  10. Mittenberg, W., Patton, C., Canyock, E., & Condit, D.  (2002). Base rates of malingering and symptom exaggeration.  Journal of Clinical and Experimental Neuropsychology, 24, 1094-1102.
  11. Slick, D. J., Sherman, E. M. S., & Iverson, G. L. (1999). Diagnostic criteria for malingered neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical Neuropsychologist, 13(4), 545-561

Additional Webinars

Visit Webinars for information on past and upcoming webinars.

Please note that some files may not be compliant with Section 508 of the Rehabilitation Act. If you need an accessible version of a particular file, please contact us and we will provide one for you.