In the study of neuropsychology, the issue of malingering, which is an exaggeration of disability for personal gain is a critical and complex matter that requires efficient detection techniques. The malingering incidents have made a significant contribution to the rise of medicolegal and forensic cases (Bigler, 2012). These fields, therefore, need to use neuropsychological evidence that concludes the test of cognitive abilities to determine the validity of the claims to memory deficiency. One of the most valid and reliable assessment criteria is the Test of Memory Malingering (TOMM) that is accurate in identifying exaggerations to memory deficiency.
Memory Malingering
Many people intentionally produce exaggerated or false psychological or physical symptoms that are motivated by external incentives. These may include avoiding work, escaping criminal persecution, avoiding military duty, obtaining drugs and getting financial compensation. They, therefore, make up the excuse for memory loss or brain injury whenever there is a record of high cases of absenteeism from work, avoiding military duty by either going A-Wall or resisting to join the disciplined forces and citing cognitive impairment when they conducted a grave crime.
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Other reasons include cases where the patient wants to use highly expensive drugs for pleasure rather than medical conditions and using malingering to commit frauds by luring companies into giving them financial compensation for brain injury leading to memory loss. The evidence produced by TOMM scores, therefore, evaluates and assesses whether there is legitimacy in the claims of cognitive deficits or there is purported exaggeration.
What the Test in Memory Malingering Measures
Through the use of clinical training and expertise, medical professionals use the TOMM successfully measure visual memory which distinguishes between malingering and real memory impairment. The distinction is through the systematic provision of the impression of the conduction of the test that tricks malinger into presenting reliable results that show neurological evidence on feigned memory impairment. During the process, the malingerers, therefore, intentionally perform poorly while those that are non-malingerers give their full efforts to do well (Bigler, 2012).
The Test of Memory Malingering also offers a norm-based criterion that is sensitive to malingering but not to cognitive impairment. This is because people with substantial cognitive impairment can store and retrieve pictures of everyday objects. Many people think that cognitively impaired people will show low scores. This is not the case. Cognitively impaired individuals perform in the same score margin as the normative sample. Therefore, low scores in the TOMM shows exaggeration for claims of memory impairment while high scores disapprove malingering.
Additionally, the Test of Memory Malingering is administered if the patient is objectively examined to show symptoms feigning or exaggeration of memory impairment and a small part of the feigned physical disability. Symptoms of exaggeration or feigning manifest in the form of the presence of incentives that are identifiable in exaggeration, application or litigation for disability in medicolegal contexts. Such manifestations include the lack of neuropsychological evaluation and results that back up their claims, inconsistent behavior that contradicts the claims and complaints as observed and the lack of sense in the medical and psychological provisions that back up the individual’s allegations (Denning, 2014).
Another factor that raises the concern for the necessity of conducting the Test for Memory Malingering is the existing contradictions between the medical reports and the verbal complaints of the person, that show in the medical reports, the scientific nature of medical findings that do not coincide with the claimed disability and lack of evaluation cooperation. The results of the test are, therefore, relevant to whether the person receives financial compensation, is a valid subject of treatment, is pardoned in a criminal case or can be excused from some responsibilities as military duties.
Initially, the test was relevant to adult populations that had sixteen years of age and above, but recent research shows that children as small as five years of age show consistent results with those of the adults (Ploetz et al., 2016). The premise of the argument is on recent testing of the correlation between the scores of children with neurological conditions which performed the same as their adult counterparts. Ploetz, Mazur-Mosiewicz, Kirkwoo, Sherman and Brooks (2016) show that the performance of children that have neurological conditions is the same as the normative samples when tested in the Test of Memory Malingering in children with neurological conditions.
How Test in Memory Malingering measures the existence of memory impairment
TOMM measures visual memory through a series of fifty –item recognition tests in the steps of two learning trials followed by an optional retention trial if the patient shows delay (Ploetz et al., 2016). The format of the TOMM test includes the Trial 1 and 2 Stimulus Booklets that have 50 target line-drawings and 50 recognition panels, the Retention Test Stimulus Booklet that has 50 recognition panels and the Response Recording Forms. The computer versions of the test are incorporated in the PsychManager in the TOMM WindowsTM-based software when the respondent is seated near a computer.
The administration of the two trials starts with the revelation of 50 line drawings of common day to day objects on a three-second basis. Each picture or drawing is shown one at a time in and has a difference of one-second interval to the examinees. This is the learning phase in the administration of the test. The Trial 1 drawings are in a booklet although there are computer versions of the TOMM that display the pictures.
In Trial 2, the subject visualizes fifty recognition panels that contain one of the pictures that appeared on the learning trail and another new picture. Every trail has a following forced-choice recognition test that has feedback for every test. The examinee is required to select a picture that was in the learning trial, Trial 1. In case of a delay, the clinical expert then uses the optional retention trial to administer the same procedures except that the target pictures are not shown. This step is used to corroborate the results of the test after the two learning trials are administered. It is, therefore, significant in cases where the respondent is not timed conscious or has cognitive impairment.
The next step of the Test of Memory Malingering is the scoring process. This procedure is conducted through the use of numerical points. One point shows the correct answer by the patient scored in the Recognition and the Retention Trials while the inability to identify the right object is marked as zero (Schroeder et al., 2013). In the compilation of the test scores, the minimum score for all wrong answers is zero while the maximum for all correct answers is fifty. Furthermore, the test uses two decision rules where the results in the feedback are assessed through the criteria of two cut scores. The first which is ‘below chance’ is based on performance that is lower than chance. However, the second that shows cognitive impaired patients or head injury based on criteria uses the based norms in the clinical samples. Low scores raise the suspicion of malingering and therefore serve the objective of the test to give clinical judgment of a malingerer.
The interpretation of the TOMM is also usually based on fundamental conceptual issues that affect the motivational factors of malingering in a patient. The interpretation is, therefore, not entirely based on the TOMM score but rather on many factors such as the person's age, medical records, inheritable traits and the criminal history. Furthermore, the C-level Qualifications in the administration of the TOMM requires its application, administration and evaluation be in accordance with the SEPT or Standards for Educational and Psychological Testing. This requirement ensures that the set professional and technical standards are met whet conducting the Test of Memory Malingering.
The validity/reliability of Test in Memory Malingering
The initial validation and development of TOMM occurred over a four year period with the use of 475 adults in a community dwelling in an age range of 17 to 84 years (Schroeder et al., 2013). 187 neuropsychological assessments classified the patients in the form of thirteen individuals with no cognitive impairment, 45 traumatic brain injuries, 21 with aphasia, 26 with depression and 40 that had dementia. In the study, non-demented individuals showed a perfect score in Trial 2 and the Retention trial. This experiment is the cornerstone of the current Test for Memory Malingering. The score which is above 45 became the standard score where if an individual scores lower that 45, it raises questions of malingering. The score also coincides with the greater than 18 correct which shows a 95% confidence level currently the statistical rule of decision when conducting the TOMM. The five experiments that used a different level of participants showed the consisted results which determine the TOMM as a useful instrument that detects deliberately faked or exaggerated memory impairment.
Kulas, Axelrod, and Rinaldi (2014) give a cross-validation of a supplemental test of memory malingering scores as performance validity measures that prove the efficiency of the TOMM. In agreement with the authors, the TOMM scores are consistent with the scores of normative patients as well as those that have cognitive impairments apart from dementia which is memory loss. The intensity of the memory loss also varies depending on the period that the patient is required to remember a phenomenon.
However, the three to four second of administration is sufficient in determining the visual capability of retention (Kulas, Axelrod & Rinaldi, 2014). Another factor that increases the reliability of the scores is that the malingerer will attempt to alter with the answers to prove memory loss without the knowledge that people that have cognitive impairment score almost the same as those that are considered as the normative sample.
The steps are time conscious such as the first step that is the development of the stimulus materials alongside the initial validation that is made to the non-cognitive impaired sample. The second step is the sensitivity validation in the various types and samples of cognitive impairments. TOMM has high levels of specificity and sensitivity while at the same time shows insensitivity to anxiety and depression (Schroeder et al., 2013). This allows for direct attempts to compare the data obtained from a person that is suspected of malingering and the TOMM scores of a person that has a similar level of neurological impairment or insult but does not possibly have malingering. Furthermore, when an individual scores below the recommended cutoff in the Retention Trial or Trial 2 or exhibits performance that is below chance in any trial, their scores are consistent with a probable response bias and suggests neurocognitive dysfunction.
Also, the validity of the TOMM is presented in two studies which include the validation of patients that are risk subjects to malingering and have suffered a traumatic brain injury and validation with stimulated malingers (Kulas, Axelrod & Rinaldi, 2014). The results, therefore, show that the TOMM is a reliable psychometric test that detects deliberately faked or exaggerated memory impairment. These validity arguments, therefore, place TOMM as a useful instrument as a clinical utility of determining the actual nature of malingering of memory deficits in patients that have other cognitive impairments apart from dementia which refers to memory loss.
Evaluations in the Test in Memory Malingering
The comparison of the retention and learning scores of cognitively impaired subjects to those of non-cognitively impaired subjects show the independence of the recognition performance to the independent recall factors in verbal and visual learning. Additionally, correlation analysis supports the results through the correlation efficient between the Test of Memory Malingering, and other measures of learning in all groups range in a margin of 0.20 to 0.35 in the three trials (Kulas, Axelrod & Rinaldi, 2014). When there is no correlation between the TOMM scores and the free recall results, it demonstrates that TOMM is insensitive to measures of memory and learning dysfunctions associated with neurological impairments. The TOMM manual presents detailed validation data.
The TOMM is used in different types of evaluations based on the cognitive status of the patient to detect visual memory ability and identify malingering (Schroeder et al., 2013). Cognitive impairment such as dementia, however, deter the effectivity of the results because the individual already suffers from frequent memory loss. The margin of the scores, however, differs in a small margin as compared to the results shown by malingerers. Due to the learning and recognition trials, the Test in Memory Malingering tests the visual memory and the retention capability of an individual.
Before the administration of the TOMM, the clinical expert evaluates the preexistent perceptual, motor, sensory, attention deficit, affective, cognitive, and behavioral factors that affect the memory of a patient. Evaluation of such factors enables the correlation between the scores and the incidence of feigning memory impairment. The assessments are also based on the diagnostic observation of the patient during the motivational factors that lead to the suspicion of faking memory loss (Wisdom et al., 2012). The multidisciplinary role, therefore, comes into play because the clinical intervener will use past records such as criminal, family, medical and penal records to assess the necessity of the Test for Memory Malingering.
Additionally, another evaluation factor that plays a significant role is a prior neuropsychological examination (Wisdom et al., 2012). This is because it determines the need for a TOMM in the case of brain injury in a patient that wants financial compensation in a case in court. Evidence from the TOMM is a significant determinant of whether the patient will be given compensation or whether they shall be charged for the disruption of justice.
Furthermore, in the administration of the TOMM evaluating the behavioral response of the patient increases the detection cases in case of malingering (Denning, 2014). Fidgeting, overthinking and taking longer to answer the questions raises suspicions on the patient's efforts to rig the test and make it harder for the clinical expertise in disapproving memory loss. Denning (2014) proposes that a combination of the TOMM Trial 1 with the behavioral responses of the patient improves the detection of effort test failure in a suspected patient. Normative behavior is usually effortless in the physical sense.
Conclusion
The Test of Memory Malingering is, therefore, the most valid and reliable cognitive tests that distinguish the existence of memory loss or impairment as opposed to actual brain injury or damage. The test helps to detect cases of malingering which posed a complex challenge in the subject or neuropsychology as an emerging issue in medicolegal and forensic cases. The other attribute that enables satisfactory evaluation in the test procedures is the use of other factors such as the behavioral responses of the individual to determine the cases of malingering. Efficient detection techniques such as TOMM detect the memory deficiency even in cognitively impaired individuals.
References
Bigler, E. D. (2012). Symptom validity testing, effort, and neuropsychological assessment. Journal of the International Neuropsychological Society , 18 (04), 632-640.
Denning, J. H. (2014). Combining the Test of Memory Malingering Trial 1 With Behavioral Responses Improves the Detection of Effort Test Failure. Applied Neuropsychology: Adult , 21 (4), 269-277.
Kulas, J. F., Axelrod, B. N., & Rinaldi, A. R. (2014). Cross-validation of supplemental test of memory malingering scores as performance validity measures. Psychological Injury and Law , 7 (3), 236-244.
Ploetz, D. M., Mazur-Mosiewicz, A., Kirkwood, M. W., Sherman, E. M., & Brooks, B. L. (2016). Performance on the Test of Memory Malingering in children with neurological conditions. Child Neuropsychology , 22 (2), 133-142.
Schroeder, R. W., Buddin, W. H., Hargrave, D. D., VonDran, E. J., Campbell, E. B., Brockman, C. J., ... & Baade, L. E. (2013). Efficacy of Test of Memory Malingering Trial 1, Trial 2, the Retention Trial, and the Albany Consistency Index in a criterion group forensic neuropsychological sample. Archives of clinical neuropsychology , 28 (1), 21-29.
Wisdom, N. M., Brown, W. L., Chen, D. K., & Collins, R. L. (2012). The use of all three Test of Memory Malingering trials in establishing the level of effort. Archives of Clinical Neuropsychology , acr107.
