Practical Considerations in The Assessment of Potential Abilities In Applicants For Benefit Programs

One of the clearest examples of such a government assistance program involves applications for Social Security disability, of which there are about two million annually in the United States (Leo, 2002). These applications, to put it crudely, involve a worker saying, in effect, that not only is she or he no longer able to support him-/herself and her/his family, as well as contribute to the welfare of those who are unable to work, but is actually in need of financial aid from those who are working and paying payroll taxes. Therefore, great care is called for in doing qualifying evaluations in that a severe error could cause a person who is actually capable of working to receive benefits at the expense of the truly disabled and additionally to not contribute to the upkeep of those with genuine disabling conditions. Obviously, the reverse negative scenario is also possible.

Not only are these evaluations important, but they are quite different in focus from general clinical evaluations conducted in hospitals and clinics in which an emphasis is placed on a diagnostic formulation of the case. While in these examinations a labeled disabled person must have a diagnosis (One can't have a disability without a diagnosis.), the bulk of the reports focus on the functional abilities of persons with such conditions as diabetes, depression, anxiety and substance abuse disorders, which vary widely among individuals placed into the same diagnostic categories.
Given that functional ability is the key question, people applying for benefits may attempt to present themselves as being potentially less functional than might actually be the case. Perhaps the best example of such a situation occurs during the course of Social Security disability applications. In fact, these are sort of reverse job interviews in which the desired outcome is that the patient can't work! There seem to this writer to be three prongs in attempting to qualify for such benefits 1. I am a very honest and responsible person. I have always worked and have never taken anything from anybody. I love to work! 2. Unfortunately however, I have this (mental or physical) condition or conditions which make it impossible for me to work. 3. Also unfortunately, I was never good at school/am not too bright, so I couldn't be retrained for some kind of office desk job in which my physical limitations wouldn't interfere.
Contention Number One above can, potentially and obviously, be confirmed or disconfirmed by such documents as employment and welfare roll records.
Number Two is more challenging in that no evaluator or decision maker can be an expert in all medical fields, including here mental health. Hopefully, however, she or he will have access to reports, such as from treating physicians. Also, In both the physical and mental health fields, an evaluator may choose to use the Wildman Symptom Checklist (Wildman & Wildman, 1999; in an effort to identify persons who are claiming to suffer from bogus physical and psychiatric symptoms, as well as presenting themselves as possessing an unrealistically high level of morality. This brief, self-administered instrument along with scoring and interpretive instructions is presented as Appendix A to this article.
Number Three of our "three-legged stool" relates to a person's functionality. In the very frequent case of an injured worker who is unable to return to his previous construction job, the relevant question could come down to whether such a person could be retrained for less physically demanding work, such as in an office. Parenthetically here, many outside workers seen by this writer express outright disgust at the prospect of being "cooped up in a cubicle." Given the above-mentioned avoidance on the part of some physically impaired applicants, it makes sense that some of them might attempt to downplay their intelligence in their interactions with evaluators, reasoning here that if they succeed in hiding their true intellectual abilities/potentials, the decision maker reading their report will conclude that he or she is not educable for a light-duty desk job and just go ahead and grant the requested benefits.
There are in this psychologist's experience a number of ways to detect such "dumbed-down" presentations: 1. Marked discrepancies between a person's level of presentation, such as in the completion of the intake forms and during the interview, and the educational and vocational background and in the absence of a dementing condition. For example, a high school graduate from a regular educational program who restricts herself to a fourth or fifth grade vocabulary might be suspected of downplaying her intelligence for the reasons explained above. 2. Inconsistent presentations. It often occurs that an applicant will use a higher level of verbal ability during one part of the evaluation than another. For example, the interview or past or present intake forms may reflect varying levels of intellectual ability.
The author has found it useful to probe a patient's receptive vocabulary following an assessment of her or his expressive vocabulary. As an illustration here, I have had success with abruptly asking an applicant displaying a very low level of speech about the last statement, "But doesn't that negate what you said earlier about this matter?" On a number of occasions, patients have quickly explained away any apparent inconsistencies, obviously indicating an understanding of the meaning of the word "negate" and strongly suggesting the potential for a higher level of cognitive functioning than had been presented up to that point.

HELP FROM PSYCHOLOGICAL TESTING
While it is not usually possible to order full-length psychological tests, such as a formal IQ test, many of which can be scored to detect malingering (Rogers & Bender, 2018), there exist brief cognitive assessment tools which are sensitive to such forms of negative patient impression management as are described in this report.
The Nevada Brief Cognitive Assessment Instrument (NBCAI; Wildman, 2008) is a 50-item matching test which correlates .83 with the WAIS-III Verbal IQ score, certainly qualifying it as a screening measure for intelligence. To date, it has been used in published studies of screening for early dementia (Brown, Lawton, McDaniel & Wildman, 2012;Wildman & McDaniel, 2014). This instrument is included as Appendix B to this article. Research with this brief, self-administered instrument shows that it can be used to predict formally-assessed IQs. The table for making these predictions is presented as Table 1.
By way of rough summary, a score of 20 predicts an IQ of about 70, obviously on the borderline of intellectual disability, and a score of 40 would be consistent with normal intelligence (about 100).
In terms of detecting negative patient impression management on the NBCAI, an evaluator should become suspicious if an applicant's educational/vocational background is grossly inconsistent with the predicted IQ. I have found it to be particularly useful to compare the client's written responses on the intake forms with the result of the NBCAI vocabulary subtest, in many cases concluding that it would not be possible for someone with such a low-level vocabulary to have produced such high-level written (or subsequently spoken) responses.
A more rigorous and statistical method for using the NBCAI to detect feigning lower levels of intelligence emerged from the report of Wildman (2018). Briefly, a ratio is calculated by dividing the number of the 20 empirically-determined easiest items on the instrument (1,2,3,12,15,20,21,23,24,28,31,32,33,34,35,36,37,38,39,40) by the total number of matching items with incorrect answers. Predicting that patients scoring .125 and higher on this index are trying to hide their true level of intelligence, while lower-scorers are making a good-faith effort produces a "hit-rate" (Wildman & Wildman, 1975) of 77%. Specifically, this index correctly identifies 87% of those downplaying their abilities and 67% of those responding honestly, employing here a broad range of data sources outside the NBCAI itself, suggesting more false positives than false negatives with respect to having the condition of malingering.
A less dramatic form of patient negative impression management relates to simply not making a good-faith effort to do as well as possible, as opposed to, say, giving wrong answers. The Reno Effort Test (Wildman, 2015), reproduced as Appendix C to this report, was designed to help in detecting such failure to exert oneself maximally during evaluations. The average person completes a little over 100 of these items in a two-minute period, so scores markedly below that figure should inspire some doubt as to how hard the person being evaluated was trying.
However and perhaps obviously, no statistical calculation, such as the ones discussed above, can be relied upon to detect or rule-out negative patient impression management. But they may provide warnings during the general clinical evaluation process, such as when the easy items missed/total items missed ratio on the NBCAI is two or three times the cutoff for suggesting the downplaying of one's level of intellectual ability.