Noncredible symptom presentation inADHDrefers to invalid, exaggerated, or feigned self-report of inattention, hyperactivity,impulsivity, or functional impairment that is inconsistent with actual abilities.
It can involve conscious feigning of symptoms for secondary gain or unconscious exaggeration of difficulties due to psychiatric factors or misattribution of common problems to ADHD.
a whiteboard with ‘symptoms of ADHD’ written in the middle, with hyperactivity, impulsivity, and inattention branching off it.
Key Points
Rationale
Accurate assessment of both ADHD symptoms and associated functional impairment is critical not only for establishing a valid ADHD diagnosis, but also for informing treatment decisions.
However, there is limited understanding of how noncredible symptom presentation impacts self-report measures used in ADHD assessments.
Overreliance on subjective self-report data can increase the risk of response biases that lead to inaccurate conclusions (Musso & Gouvier, 2014).
While emerging research shows that self-report measures of ADHD symptoms and functional impairment ratings are vulnerable to noncredible responding in simulation studies (e.g., Wallset al.,2017), no study has examined this using formal classification criteria for noncredible presentation or investigated whether it affects the relationship between self-reported symptoms and functional impairment.
As such, this study aimed to classify adults undergoing ADHD evaluations as credible or noncredible responders using Shermanet al.’s (2020) criteria in order to examine group differences in self-reported ADHD symptoms, psychological symptoms, and functional impairment.
Additionally, this study tested whether noncredible presentation moderates the association of symptom severity to perceived functional impairment.
Method
Sample
Statistical Analysis
Results
As hypothesized, the noncredible group reported significantly greater symptoms than the credible group with large effect sizes, including:
The noncredible group also reported greater psychological symptoms than the credible group with large effect sizes, including:
Additionally, the noncredible group reported significantly higher functional impairment than the credible group, with alarge effect size(5.54 vs 3.58,p< .001, d = 1.37).
Insight
A key insight is that while ADHD symptoms and functional impairment are inherently related constructs, noncredible symptom presentation seems to weaken their association.
For credible responders, greater self-reported ADHD and psychological symptoms were moderately-to-strongly correlated with higher perceived functional impairment. However, most bivariate relationships between self-reported symptoms and perceived functional impairment were small and non-significant for noncredible responders.
Additionally, relationships between perceived functional impairment and symptoms specifically related to depression and anxiety were significant for credible responders but not for noncredible responders.
This pattern suggests that noncredible responders report elevated symptoms without necessarily linking them to impairment in major areas of life activities. In contrast, credible responders may be more likely to perceive their symptoms in the context of disruptions in their daily functioning.
By showing that noncredible presentation impacts subjective symptom report and its relationship to perceived functional impairment, this study underscores the need for multi-method assessment approaches.
Using both symptom and performance validity tests can improve the accuracy of symptom and impairment ratings and guard against response biases leading to inaccurate diagnostic decisions or treatment planning.
Strengths
The study had several methodological strengths:
The standardization of symptoms scores and functional impairment ratings based on normative samples increased interpretability of the data.
Limitations
However, the study had some limitations:
Implications
Additionally, it raises concerns about relying predominantly on patient self-report when assessing impairment, highlighting the need for multi-method evaluation approaches.
Clinicians are urged to consider both symptom and performance validity testing when diagnosing ADHD in adults to improve diagnostic accuracy and treatment planning.
The finding that symptoms of depression and anxiety were strongly tied to perceived impairment for credible but not noncredible responders also carries important clinical implications. It suggests that noncredible presentations may obscure the typical comorbidity between ADHD and internalizing disorders.
Failure to identify comorbid conditions could negatively impact prognosis if left untreated alongside ADHD interventions.
Additionally, the weakening of associations between self-reported symptoms and impairment among noncredible responders indicates that perception of disability serves an important validating role in the assessment of ADHD.
Broader implications pertain to the assessment of other mental health conditions, especially those relying heavily on self-report data. Similar patterns may emerge wherein noncredible responding artificially inflates perception of symptoms separate from functional disability.
As such, clinicians across disciplines should be cognizant of the potential disconnect between subjective symptom report and objectively measured dysfunction when evaluations risk biased responding.
References
Primary reference
Lee, G. J., Do, C., & Suhr, J. (2023). Noncredible presentations of symptoms and functional impairment in the assessment of adult attention-deficit/hyperactivity disorder.Psychology & Neuroscience, 16(3), 284–301.https://doi.org/10.1037/pne0000319
Other references
Musso, M. W., & Gouvier, W. D. (2014). “Why is this so hard?” A review of detection of malingered ADHD in college students.Journal of Attention Disorders, 18(3), 186–201.https://doi.org/10.1177/1087054712441970
Sherman, E. M. S., Slick, D. J., & Iverson, G. L. (2020). Multidimensional malingering criteria for neuropsychological assessment: A 20-year update of the malingered neuropsychological dysfunction criteria.Archives of Clinical Neuropsychology, 35(6), 735–764.https://doi.org/10.1093/arclin/acaa019
Walls, B. D., Wallace, E. R., Brothers, S. L., & Berry, D. T. R. (2017). Utility of the Conners’ Adult ADHD Rating Scale validity scales in identifying simulated attention-deficit hyperactivity disorder and random responding. Psychological Assessment, 29(12), 1437–1446.https://doi.org/10.1037/pas0000530
Keep Learning
Here are some thought-provoking discussion questions about this research a college class could explore:
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
