ADHD

the

R E P O R T
Russell A. Barkley & Associates
• Volume 27 • Number 5 • ISSN 1065-8025 • August 2019 •

Is Neuropsychological Testing Useful for Any

Reason in the Evaluation of ADHD?
A Rejoinder to Mapou
Russell A. Barkley, Ph.D., and Robert Eme, Ph.D.

In the March 2019 issue of The ADHD be used to falsely rule in the disorder evaluations. We view them as having
Report, Barkley critically challenged when the deficient results could be due as limited an evidence base related to
the view that neuropsychological test- to another disorder (test anxiety, learn- ADHD as that for the role of NPT in
ing (NPT), particularly of executive ing disability, intellectual disability, diagnosing ADHD.
functioning (EF), is useful in making schizophrenia, depression, etc.) or due In defense of using NPT in an evalu-
the diagnosis of ADHD. His opinions to malingering. ation, Mapou noted the following justi-
were limited in scope to evidence re- In his rebuttal to Barkley’s article, fications for its continued use:
garding the testing aspect of an evalu- Mapou (2019) essentially agreed 1. Like Barkley, Mapou supported
ation. It did not criticize the broader with Barkley’s position that NPT was the value of intelligence and achieve-
practice of a standard psychological not useful in making the diagnosis of ment testing as part of a larger neu-
evaluation that includes history, re- ADHD. But he then went on to cham- ropsychological evaluation of ADHD.
cords review, rating scales, interviews
pion the value of NPT in the evalua- But this was not an issue challenged by
about current symptoms and function-
tion of clients with ADHD for other Barkley. The value of such tests was, in
ing, and so forth. Instead this article fo-
reasons. Here we wish to challenge the fact, specifically acknowledged in and
cused on the role of NPT in making the
basis of even those presumed advan- excluded from his criticism of NPT. Af-
diagnosis of the disorder. That article con-
tages or contributions of NPT in such ter all, IQ and achievement testing are
cluded that there was no compelling
evidence for this widespread practice
and much evidence to argue against it.
He encouraged clinicians to either stop
Contents
the practice or, if not, prove its utility.
Barkley noted that, in fact, exclusive Is Neuropsychological Testing Useful for Any Reason in the
or excessively weighted reliance on
the NPT results could be misleading in Evaluation of ADHD? A Rejoinder to Mapou, 1 • Psychosis
many cases. It would most often rule
out the disorder when it in fact exists and Stimulant Treatment: A Reality Check, 9 • Research
in a patient based on standard diag-
nostic criteria (a problem of excessive Findings, 11
false negative rate). But he also noted NOTICE TO NON-PROFESSIONALS The information contained in this newsletter is not intended as a
substitute for consultation with health care professionals.
that, to a lesser extent, results might

© 2019 The Guilford Press The ADHD Report • 1

Russell A. Barkley, Ph.D. not so much neuropsychological tests don et al., 2006), the terms symptoms and
Virginia Treatment Center for Children
Virginia Commonwealth University as psychological and psychoeducation- impairment are often used interchange-
School of Medicine al ones often included in non-neuropsy- ably when they clearly should not be.
Send correspondence to
drbarkley@[Link] chological evaluations of patients. The According to those authors, symptoms
fact that neuropsychologists may use in psychiatric disorders reflect the cog-
Dr. Russell Barkley discloses that his work includes serving them for the same purposes as others nitive and behavioral expressions of a
as a paid Speaker/Consultant for pharmaceutical companies
in his area of expertise.
does not somehow salvage the argu- disorder. They are the mental and be-
ment that comprehensive NPT itself is havioral manifestations of the person
useful, especially that focusing on EF. by which one recognizes the presence
ADVISORY BOARD
Kevin Antshel, Ph.D., Syracuse University • José And unlike for learning disabilities (LD) of some underlying disorder. In ADHD,
J. Bauermeister, Ph.D., University of Puerto Rico, or intellectual disability (ID), test results that would be the manifestation of the
San Juan • Stephen P. Becker, Ph.D., Cincinnati
are not formally a part of the definition inattentive, impulsive, and hyperactive
Children’s Hospital Medical Center • Will Canu,
Ph.D., Appalachian State University • Anil Chacko, and diagnostic criteria for ADHD. If behaviors comprising its diagnostic cri-
Ph.D., New York University • Andrea M. Chronis, they were, we would encounter more teria. Impairment, by contrast, refers to
Ph.D., University of Maryland, College Park •
George J. DuPaul, Ph.D., Lehigh University, PA •
appropriate labels, such as continuous the adverse consequences that occur to
Gregory Fabiano, Ph.D., University of Buffalo • performance test (CPT) reaction time the individual resulting from those cog-
Jeff Epstein, Ph.D., Cincinnati Children’s Hospital variability disorder, or card sorting dis- nitive and behavioral manifestations
Medical Center • Sam Goldstein, Ph.D., University
of Utah, Salt Lake City • Cynthia M. Hartung, Ph.D., order, or digit span backward disorder. and the ineffective functioning they cre-
University of Wyoming • Stephen Hinshaw, Ph.D., Instead, ADHD is defined by its be- ate in a major life activity, such as edu-
UC Berkeley • Betsy Hoza, Ph.D., University of
Vermont • Charlotte Johnston, Ph.D., University
havioral symptom constellations, their cation or occupational functioning. The
of British Columbia, Vancouver • Laura E. Knouse, history and persistence, pervasiveness, person demonstrates the symptoms; the
Ph.D., University of Richmond, VA • Scott Kollins, and developmental inappropriateness, environment kicks back with its nega-
Ph.D., Duke University Medical Center, Durham,
NC • Sandra Kooij, M.D., Expertise Center Adult the presence of impairment (personal tive consequences. Those consequences
ADHD, The Netherlands • Joshua Langberg, Ph.D., suffering or ineffective functioning in comprise the harm that the disorder
Virginia Commonwealth University • Florence
major life activities), and the exclusion leads to or causes in a specific ecology.
Levy, M.D., The Prince of Wales Children’s Hospital,
Australia • Larry Lewandowski, Ph.D., Syracuse of other disorders that may account for Such harm or impairment can be any of
University, NY • Sandra Loo, Ph.D., Neuropsychiatric the clinical presentation. at least three forms, as Wakefield (1992,
Institute, UCLA • Keith McBurnett, Ph.D., University
of California, San Francisco • Richard Milich, 2. Mapou goes on to assert that NPT 1997) noted in his definition of a mental
Ph.D., University of Kentucky, Lexington • Brooke is essential to determine if accommodations disorder as a “harmful dysfunction”:
Molina, Ph.D., University of Pittsburgh • Kevin
Murphy, Ph.D., Adult ADHD Clinic of Central
are necessary. As mentioned by Mapou, (1) increased risk for earlier mortality;
Massachusetts • Joel Nigg, Ph.D., Oregon Health the fact that various testing, educa- (2) increased risk for greater morbidity
Sciences University, Portland, OR • Linda Pfiffner, tional, and government agencies may or injury; and (3) significantly ineffec-
Ph.D., University of Chicago • J. Russell Ramsay,
Ph.D., University of Pennsylvania Perelman School require NPT as evidence of ADHD or of tive functioning in a domain of major
of Medicine • Mark Rapport, Ph.D., University impairment is not a very compelling ar- life activity (educational, occupational,
of Central Florida • Luis Rohde, M.D., Federal
gument given that there is no evidence social, community, or adaptive func-
University of Rio Grande do Sul • Julie Schweitzer,
Ph.D., UC-Davis MIND Institute, Sacramento, CA • to our knowledge that supports the va- tioning [self-care and independence],
Mary V. Solanto, Ph.D., Hofstra Northwell School lidity of NPT in doing so. Instead, these among others) that leads to adverse
of Medicine • Dan Waschbusch, Ph.D., Penn State
University Medical Center • Jeanette Wasserstein,
various agencies are misguided in stip- consequences.
Ph.D., The Mount Sinai School of Medicine • Lisa ulating this requirement in their docu- ADHD qualifies as a disorder by any
Weyandt, Ph.D., University of Rhode Island • Alan mentation of ADHD and its need for ac-
Zametkin, M.D., Private Practice
of these impairment criteria, though
commodations in view of the available it actually meets all three—it increas-

THE ADHD REPORT (ISSN 1065-8025) is published bimonthly
dearth of evidence for doing so. es mortality risk (Barkley & Fischer,
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Copyright © 2019 by The Guilford Press. As Barkley and others have argued impulsive behavior so as to be punished
Printed in the United States of America.
elsewhere (Barkley, 2011a, 2012a; Gor- in or suspended from school more often

2 • The ADHD Report © 2019 The Guilford Press

than others or have no close friends. per agency guidelines rather than actu- be counterproductive to obtaining ac-
All are adverse consequences accruing ally documenting impairment in fact commodations. Most cases involving
from symptom manifestations in the or reality. Yet it is a sad fact of clinical ADHD obtain normal scores on NPT.
educational domain. practice that neuropsychologists must If Mapou’s reasoning is correct, and de-
According to this conceptualization sometimes play the game of giving the ficient test scores should be a basis for
of symptoms and impairment, a defi- tests in order to get accommodations, granting accommodations, then normal
cient score on a psychological test or inappropriate as this requirement may test scores should be a basis for deny-
NPT is a symptom or symptom-corre- be in light of the evidence base. ing them. So what happens in the cases
late of ADHD, not evidence of impair- Even so, one can rightly question just where NPT results are normal in oth-
ment. Although EF deficits are not (yet) what sort of accommodation one would erwise legitimate cases of ADHD? Are
official symptoms of ADHD, they are need to make in the performance of a they to be denied accommodations?
well established symptom correlates of particular vocation or in an education- Mapou’s reasoning implies they should
it. This is particularly so with regard to al environment that results from such be. Here he falls prey to the same prob-
ratings of EF in daily life, with which a test result that is based on any evi- lem Barkley revealed about testing for
the inattention dimension of ADHD is dence linking the abnormal test score diagnosis—the test result is neither ac-
highly correlated and may actually be to the accommodation. As noted above, curate nor valid for making such a deci-
collinear (equivalent; Barkley, 2011b, we are not aware of any evidence that sion, whether it is about the diagnosis
2012b). A deficient test score therefore links deficient test scores to specific ac- or about impairment in real life and
commodations that are proven useful hence the accommodations it requires.
may not be a valid index of a diagno-
(valid) to make in those instances. For The assumption of the test as a valid in-
sis of ADHD or evidence of its symp-
example, is there a proven link between dex of anything other than performance
toms, as Barkley argued previously. It
slow processing speed on the Wechsler on the specific neuropsychological test
is also not evidence of impairment by
Adult Intelligence Test and slow perfor- lacks compelling evidence. For instance,
the above conceptualization, and so of-
mance on an occupationally or educa- when one fails the Wisconsin Card Sort
fers no real basis for the justification of
tionally related task? We are not aware Test categories score, it may be evidence
any accommodation that is designed
of such predictive correlations. Indeed, of poor flexibility or set shifting in per-
to reduce impaired functioning. For
as previously noted, the correlations forming that test, but we are aware of
instance, a deficient (significantly el-
between test scores and impairments no evidence that it is highly correlated
evated) omission score or reaction time
are relatively low, such that they share with cognitive flexibility in major do-
variability score on a CPT may suggest
about 10% of their variance or less (see mains of life activities. Most people
evidence of inattention during such
earlier references). Hence, contrary to with ADHD pass this much-venerated
testing (and perhaps little more). As test of EF, as Barkley argued. Yet Mapou
the requirements of agencies for test-
such, it reflects the symptoms of ADHD would have us believe it or other test
ing to support impairment in function-
as they influence test performance. But scores are valid indices of impairment
ing in a major life activity, test scores
it is not evidence of the negative ad- or lack of it in some major life activity;
offer no such evidence. Instead, they
verse consequences in a major life activ- in this case, occupational functioning.
are yet more evidence of symptoms or
ity that results from those symptoms. Where is the proof? Barkley & Murphy
symptom correlates, and not especially
Just what harm is a deficient CPT score valid or reliable ones at that. It is tell- (2010) found that neuropsychological
causing? What domain of major life ac- ing that the accommodations given as EF tests offered little predictive value
tivity does performing a CPT represent? examples by Mapou as arising from when studying 11 measures of occupa-
No obvious domain that we know of at testing would just as easily (and likely tional functioning, especially in contrast
this time. did) arise from the interview, rating to EF rating scales. Our point here is not
Of course we recognize that testing, scales, or other sources of information to champion the use of rating scales but
educational, or government agencies about the patient’s symptoms, real-life to criticize the practice of NPT.
may have their own definitions for the functioning, and impairments resulting 3. Mapou further asserts that testing
term impairment. Some may regard a therefrom based on these other sources can determine if there are neuropsycho-
cognitive or behavioral deficit or excess obtained from the patient. It is tempting logical deficits that could affect employ-
as impairing, in which case the abnor- here to call for research that examines ment in a sensitive field. Again, we can
mal test result fulfills their requirement what impairments or accommodations rightly ask, where is the evidence for
for identifying a person as impaired. neuropsychologists would stipulate as this claim? To make such a claim one
Again, the issue here may be the poor being necessary if they were given no would need proof that the deficient test
conceptualization or evidence base other information about the patient ex- score in fact predicts deficient job per-
used to create the agency’s require- cept the test scores and what evidence formance in that sensitive field. Does
ment, highlighting the need for them actually links the test score to such stip- it? One would also have to show that it
to be better educated by clinical profes- ulations. does so over and above what informa-
sionals on this matter. In this case, cli- In view of the graphic and other evi- tion on the matter is gleaned from the
nicians are merely playing the agency’s dence provided in the earlier article by IQ test commonly given as part of an
game of documenting impairment as Barkley (2019), the NPT results may ADHD evaluation, or any other source

© 2019 The Guilford Press The ADHD Report • 3

of information taken from the patient, clusion one would be compelled to score that was not gathered in the eval-
such as the interview. There exists a reach given that most ADHD clients uation through other means and that
significant correlation of IQ with many pass NPT. For instance, most teens and is singularly revealed by testing? We
(though not all) EF tests (Ardila, Pine- adults with ADHD can pass the EF tests are never told. Later in the article it is
da, & Rosselli, 2000; Friedman et al., yet their driving records are often filled said that NPT can help understand “the
2006; Mahone et al., 2002; Riccio, Hall, with adverse consequences. Either we strengths, unique challenges, and co-
Morgan, Hynd, & Gonzalez, 1994). And must conclude that driving does not occurring disorders in individuals with
EF tests correlate as well with academic involve EF (an unlikely conclusion) or ADHD.” Perhaps that is what Mapou
achievement test scores (Biederman that the EF tests are not evaluating EF in meant by understanding the whole per-
et al., 2008; Gropper & Tannock, 2009; real life (a more likely conclusion). We son. But as we noted above, NPT tests
St. Clair & Gathercole, 2006; Thorell, can also ask at what risk have we placed scores are limited in their prediction of
2007). This means that some or all of the the client or the public involved in that performance in real world domains of
variation in occupational functioning sensitive profession in rendering such a functioning. And as Barkley pointed
believed to be explained by the EF test benign conclusion from a passing test out, NPT is poor at identifying other
results may simply reflect their overlap score? As Barkley argued about NPT mental disorders with the exceptions
with that variance explained by IQ or in ADHD diagnosis, the evidence does of IQ and achievement tests for iden-
achievement scores. Again, we respect- not warrant making such high stakes tifying intellectual disability (ID) and
fully ask, where is the evidence that the decisions about people’s lives or public learning disabilities (LDs), which are
addition of EF tasks adds incremental safety on the basis of NPT results. essential tests in assessing for ID and
value to such occupational prediction 4. The very same arguments made LDs (American Psychiatric Association,
beyond the brief screening tests already above against NPT could be made for 2013; Fletcher, Lyon, Fuchs, & Barnes,
being done (IQ, achievement)? the next assertion by Mapou that NPT 2018).
Further, does inattention or impul- helps to understand how the underlying However, to return to a point previ-
sivity on a CPT, for instance, correlate pattern of NP strengths and weaknesses ously made, embedding such tests in
well with any aspect of occupational is contributing to the problem. As far as comprehensive NPT does not somehow
functioning? Does any other commonly we know, the only thing it reveals is the salvage the usefulness of comprehen-
used EF test? Prior evidence suggests pattern of strengths and weaknesses of sive NPT in such evaluations. As noted
these and other EF tests do not do so the client on those specific tests on that in the second edition of the authorita-
(Barkley, & Fischer, 2011; Barkley & day! Our criticisms above apply here as tive text on learning disabilities, there is
Murphy, 2010). The same question can well. The evidence for the predictive va- no evidence that “assessment of cogni-
be raised for NPTs of interference con- lidity of the test scores for occupational tive skills adds value to intervention,”
trol, working memory, planning, or or any other domain of functioning in and there is a “lack of evidence that
flexibility (set shifting), among other the field of ADHD is woefully lacking intervention based on cognitive skills
components of EF. We are not aware of at the moment as far as we can tell. If, generalize to academic skills” (Fletcher
such evidence of validity in predicting as Barkley showed, EF test scores can- et al., 2018, p. 5). Or, at the very least,
job performance in sensitive fields. In- not even predict (correlate well with) “Proponents of comprehensive cogni-
deed, Barkley’s research on driving per- ratings of those same EFs in daily life, tive assessments for learning disability
formance deficits and related impair- the NPT scores are not likely to reflect identification must do more to rigor-
ments in teens and adults with ADHD or predict occupational functioning or ously evaluate their beliefs or else con-
has repeatedly found that lab tests, in- performance in any other major do- cede the argument to those with better
cluding driving simulators, are not well mains of daily life activities in natural evidence” (Schneider & Kaufman, 2017,
correlated if at all with actual driving settings apart from school achievement p. 8). Once again, we challenge advo-
performance on the road. Nor are they scores. This seems even more likely to cates of NPT to prove it!
predictive of adverse driving outcomes be the case when IQ is controlled in 6. Another assertion made by Ma-
(crashes, citations, license suspensions, such analyses, given the significant cor- pou with which we take exception is
etc.). Rating scales of actual driving be- relation of IQ with performance on NPT that testing contributes to treatment rec-
havior completed by clients or others, as noted by Barkley. So, again we ask, ommendations and can improve treatment
including those taken while observing a where is the evidence showing one can outcomes. He cites the Pritchard and col-
patient in a simulator, were much more legitimately connect patterns of NPT re- leagues’ studies (2012, 2014) that those
useful in doing so (Barkley, 2015a; Bark- sults as an explanation for the cause of a who got testing initiated more behav-
ley & Cox, 2007). presenting clinical problem? ioral parent training, special education
And the same problem as noted 5. It was claimed by Mapou that services, and medication use than those
above can be raised again here—does testing is crucial for “understanding with ADHD who did not receive test-
passing the NPT mean the client has the whole person.” It is unclear to us ing. However, when one actually reads
no problems in performing their work just what that actually means. What these reports, we see a very different
in that sensitive field as a result of their is it about the whole person that is so set of conclusions from their actual re-
ADHD? Yet that is the most likely con- important to understand from the test sults. For instance, the authors stated

4 • The ADHD Report © 2019 The Guilford Press

that, “Neuropsychological testing must to access treatment and also more likely than those participants who completed
justify the necessity of often costly and to have provided resources (unmea- both study time points. Therefore, the
time-consuming neuropsychological sured by the study) that would result improvement may have been due to
assessments in the diagnosis and treat- in a more favorable outcome. No evi- the loss of the most socially impaired
ment” of ADHD. “Controlled studies dence was presented that validated the participants at follow-up. Pritchard
directly examining the impact of neu- psychometric adequacy of the question- and colleagues (2014, p. 26) concluded:
ropsychological assessments in improv- naire (standardization, reliability, valid- “With further research, neuropsycho-
ing outcomes on children with ADHD” ity) used to evaluate outcomes. Attri- logical assessment may one day reach
are needed (Pritchard, Nigro, Jacobson, tion was substantial, 30% for NP+ and the status of an evidence-based inter-
& Mahone, 2012, p. 54). This is a call for 39% for NP-. vention for ADHD.” Based on the infor-
research, not a provision of evidence There are problems as well with the mation provided here, that day has yet
justifying the use of tests for treatment results of that 2014 study. First, the au- to arrive.
planning. thors describe the study as offering a Further, even if some day numerous
In our reading, the Pritchard and col- “preliminary evaluation” of the added RCT studies will have been conducted
leagues’ (2012) study provides no evi- value of neuropsychological assess- to evaluate the usefulness of NPT to
dence for such a claim. It simply argues ment (compared to routine care) to the improve ADHD outcomes, the pros-
that the “available literature suggests identification and treatment of youth pect that the findings will be positive
that neuropsychological assessment with ADHD. So if there is any evi- receives no support in a related field of
provides information that can “poten- dence, it is at best “preliminary.” And research. That field deals with LDs. And
tially” (our italics) reduce risk for poor the preliminary evidence for outcome its results bolster our argument that the
outcomes and improve quality of life is as follows. There was no supporting considerable amount of research on
among children with ADHD (p. 54). The evidence for identification. What other the lack of value of NPT for improv-
article stresses the need for controlled evidence was there? First, the NP+ ing treatment outcomes for LDs offers
studies to determine whether this po- group was more likely to initiate par- scant hope that NPT will improve treat-
tential has been actualized. Mapou can ent management training, special edu- ment outcomes for ADHD when and
find only one such study (Pritchard, Ko- cation services, and medication man- if such research is ever done. Consider
riakin, Jacobson, & Mahone, 2014) that agement. However, a majority or vast the results of a meta-analysis of 37 RCT
provides “some” evidence. We find the majority of NP+ group did not initiate studies that evaluated the usefulness
evidence offered by this single study to any of these services: 80% did not ini- of NPT to develop interventions for
be extraordinarily weak for the follow- tiate parent management, 60% did not reading and mathematics (Burns et al.,
ing reasons. First, we address the issues initiate medication treatment, and only 2016). The authors concluded: “Taken
with the study’s design and then with 22% were identified for special educa- together with previous research, the
the results. tion services. This is hardly compelling data do not support the use of cognitive
The study is not a controlled study evidence of the value of NPT in obtain- measures to develop interventions” (p.
involving randomization to neuropsy- ing treatment. Further, the difference in 28). Even proponents of the value of
chological assessment or not. It is an initiation might well be due to selection comprehensive cognitive assessment
observational study involving a com- bias. Those caregivers who engaged for the diagnosis and treatment of LDs
parison group. So, apparently, not a in costly and time-consuming neuro- acknowledge that the evidence base
single randomized controlled study psychological assessment might be far consists mostly of scholarly assertions
(RCT) currently exists! The participants more motivated to initiate services for “backed by rhetoric in which assertions
were 188 caregivers of youth recruited their children than those caregivers are backed by citations of still other
in various ways, 53 with a neuropsy- whose children did not receive such an scholars making assertions” (Schneider
chological assessment (NP+) and 135 assessment. Lastly, there was no differ- & Kaufman, 2017, p. 9). Thus, and to
without (NP-). Caregivers filled out a ence between the two groups in terms reiterate, there is no evidence that “as-
questionnaire upon recruitment and 5 of service use, only in initiating efforts sessment of cognitive skills adds value
months later. No information was gath- to obtain services! to intervention,” and there is a “lack
ered on characteristics of the caregiv- Second, the study found no evidence of evidence that intervention based on
ers. Therefore, in stark contrast to all for improved academic, behavioral, or cognitive skills generalizes to academic
quality observational studies, there was emotional functioning. These outcomes skills” (Fletcher et al., 2018, p. 5).
no attempt to control for potential con- are exactly the critical outcomes that Lastly, the lack of evidence to sup-
founders. For example, there may have expensive, time-consuming testing is port the usefulness of NPT on im-
been a socioeconomic status (SES) dif- supposed to improve. Social function- proved outcomes in ADHD, reading
ference between the two groups which ing was improved, but no effect size and mathematics, also extends to gen-
influenced outcome—that is, given the was provided. This finding however eral psychological testing and general
costly nature of neuropsychological might be spurious. Those in the NP+ clinical services. Hunsley & Allen (in
testing, the NP+ group may have been group lost to follow-up (30%) were rat- press) concluded: “There is very little
more affluent and therefore more likely ed as having greater social difficulties replicated evidence that psychological

© 2019 The Guilford Press The ADHD Report • 5

assessment data have a direct impact confidently detect malingered ADHD” first evaluation versus the second one.
on improved provision and outcome (p. 186). Rabbitt (1997) has likewise challenged
of clinical services.” Therefore, if costly Second, a recent meta-analysis of ma- the reliability and validity of NPT for
and time-consuming neuropsychologi- lingering detection measures for ADHD the domains of EF. Even the time of
cal assessment improves ADHD out- using college student samples (Wallace day when the tests are given may have
come, prove it! et al., 2019), which included the fourth some detrimental or beneficial effects
7. Finally, Mapou argues for the value study cited by Mapou (Suhr, Sullivan, on certain EF tasks (Bennett, Petros,
of performance validity testing to detect and Rodgriquez, 2011), offered good Johnson, & Ferraro, 2008). Similarly,
malingering as a justification for NPT. support for the validity of stand-alone identifying LDs on the basis of a battery
But he contradicts himself with his own measures such as the Test of Memory of psychometric tests administered on a
rhetoric here. First, it should be noted Malingering. But there was no evidence single occasion “will not lead to reliable
that he accepts that NPT in and of it- in the meta-analysis for incremental va- identification if the approach is based
self lacks validity, that is, “studies have lidity in embedding such measures in on strictly applied cut-off scores or for-
shown that individuals trying to fake NPT. In conclusion, there is no evidence mulae” (Fletcher et al., 2018, p. 62), as
ADHD can produce profiles on neuro- that supports the validity of compre- is the typical practice. If such testing is
psychological testing that are indistin- hensive NPT in detecting malingered not reliable, then it cannot be especial-
guishable from profiles of individuals ADHD. That is not just our own impres- ly valid, as the former places obvious
with documented ADHD.” However, sion but is that of Musso and Gouvier limitations on the latter. Further, Bar-
he then attempts to make a case for the (2014) in their own review of measures kley and many others (see Chen et al.,
value of NPT to detect malingering by for detecting malingering of ADHD in 2008) have previously noted the serious
asserting “there is very good research” college students. Subsequent research problems with the ecological validity of
showing that psychomotor vigilance on adults with ADHD continues to sup- such tests, among other reasons Barkley
task (PVT) measures embedded in port our claim that even symptom or noted earlier to challenge the claim that
NPT can detect malingering, citing performance validity tests may not be EF tests can be considered valid or the
four supporting studies. Our response especially useful at detecting malinger- gold standard for the evaluation of the
is twofold. First, he mischaracterizes ing of ADHD (Hirsch & Christiansen, construct of EF.
the support this research supposedly 2015). Our last point is that the greatest
offers in three of the four studies. The problem we see here underlying any
Jasinski and colleagues’ study (2011) Final Remarks argument for the utility of NPT for
is irrelevant, as it evaluated symptom We wish to raise two final points about EF or ADHD evaluations is one that
validity measures not PVT. The study the argument that NPT is useful for oth- is often overlooked yet remains to be
of Marshall, Hoelzle, Heyerdahl, and er reasons in the evaluation of ADHD satisfactorily established. This is the is-
Nelson (2016) offered no support for even if it is not useful for making a di- sue of adequate item sampling. Do the
NPT detection of malingering. It was a agnosis. First, the arguments in favor items on the test represent the larger
retrospective study that examined how of NPT all assume that satisfactory re- construct as seen in the natural world
many adult patients (N = 554) would liability of the test results has been es- and claimed to be assessed by the test?
plausibly receive a diagnosis of ADHD tablished. We already know from above For an EF test to predict anything other
if performance and symptom validity that evidence for validity is lacking. But than tests similar to itself, the developer
measures were not administered during do clients with ADHD even get a con- must show that the test corresponds to
neuropsychological testing. A total of sistent pattern of scores when tested the larger construct claiming to be mea-
102 were diagnosed with ADHD based on repeated occasions across time (test- sured by the test. Most often this is done
on cognitive testing, behavior rating retest reliability)? Some evidence indi- simply by showing that the test corre-
scales, effort testing, and clinical effort; cates individuals do not provide consis- lates with other previously used tests
115 were identified as putting forth sus- tent patterns of test scores. Chen, Shum, said to assess that construct. But this
pect effort. The authors concluded that Toulopoulou, and Chen (2008) noted is circular reasoning (tests predicting
suspect effort and ADHD groups were this same limitation in their review of other tests), limited (to predicting test
nearly indistinguishable on ADHD be- tests of EF, where they commented on performance), and unconvincing for
havior, executive function, and func- the limited test-retest reliability of such our purposes here (making high stakes
tional impairment rating scales. The measures. And then there is a study by decisions about people in real life)—do
third study, a review of malingered Salthouse (2007) that found large indi- the tests satisfactorily predict anything
ADHD in college students by Musso vidual differences among adults in their other than their own content or that
and Gouvier (2014) also offered no sup- neuropsychological profile of 16 cogni- of other highly similar tests? In other
port. The authors concluded: “While tive tests over a period of 2 weeks on words, is there evidence of far transfer
there is some variability in the useful- retesting. That means a clinician would from the test results and not just near
ness of neuropsychological test failure, be making very different conclusions transfer?
profiles between malingerers and indi- and recommendations about the same The clinical application of NPT is as-
viduals with ADHD are too similar to clients based on the test results in the sumed to adequately sample the larger

6 • The ADHD Report © 2019 The Guilford Press

EF constructs as they occur in real life in evaluation of people with ADHD for Barkley, R. A., & Murphy, K. R. (2010).
such a way that the test results can be making high stakes decisions about Impairment in occupational functioning
used to infer those same abilities (con- their lives. and adult ADHD: The predictive utility of
executive function (EF) ratings vs. EF tests.
structs) in natural settings. That is how
Archives of Clinical Neuropsychology, 25,
clinicians are using them, and Mapou is Dr. Barkley is Clinical Professor of Psy- 157-173.
no exception. He wants to make deci- chiatry at the Virginia Treatment Center Barkley, R. A., & Fischer, M. (2019). Hyper-
sions about real life functioning, accom- for Children and Virginia Commonwealth active child syndrome and estimated life
modations, and treatments if deficient University Medical Center, Richmond. He expectancy by young adult follow-up: The
scores are evident on NPT. But given is Editor of The ADHD Report and can be role of ADHD persistence and other poten-
the simplistic and largely cognitive na- reached via e-mail at: drbarkley@russellbar- tial predictors. Journal of Attention Disorders.
ture of many EF tasks, can that actually Epub ahead of print.
[Link]. Dr. Eme is a retired Professor of
be done? For instance, how does the de- Psychology and can be reached via e-mail at Bennett, C. L., Petros, T. V., Johnson, M., &
liberation and execution of arranging a Ferraro, F. R. (2008). Individual differences
robeme@[Link].
pattern of concentric rings on spindles in the influence of time of day on executive
functions. American Journal of Psychology,
on a 20-minute tower task actually
121, 349-361.
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© 2019 The Guilford Press The ADHD Report • 7

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8 • The ADHD Report © 2019 The Guilford Press