Archives of Clinical Neuropsychology
19 (2004) 73–88
The effects of motivation, coaching, and knowledge
of neuropsychology on the simulated
malingering of head injury
Department of Psychology, The Colorado College, 14 East Cache La Poudre Street,
Colorado Springs, CO 80903, USA
Accepted 3 September 2002
Two student groups, introductory psychology (n = 91) and advanced neuroscience (n = 34) under-
graduates, were asked to malinger a head injury on Rey’s 15-Item Test (FIT) and Dot Counting Test
(DCT). The participants were randomly assigned to one of three motivation conditions (no motivation
given, compensation, avoidance of blame for a motor vehicle accident) and to one of three coaching
lingering detection). Analyses revealed a Motivation×Student Group interaction on the FIT, indicating
that the advanced neuroscience students, particularly when in the compensation condition, malingered
the most flagrantly. On the DCT, main effects for motivation and coaching on the qualitative variables
and a Motivation ×Coaching interaction on the accuracy variables indicated that those in the compen-
sation condition performed the most poorly, and that coaching plus warning only tempers malingering
on memory tasks, not timed tasks.
© 2002 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.
Keywords: Malingering; Head injury; Motivation; Coaching
Simulation experiments in the malingering of head injury have provided valuable informa-
tion about how normal individuals would feign brain damage. It has been shown, for instance,
∗Tel.: +1-719-389-6598; fax: +1-719-389-6284.
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K. Erdal / Archives of Clinical Neuropsychology 19 (2004) 73–88
that malingerers generally overestimate the impairments associated with head injury (e.g.,
Coleman, Rapport, Millis, Ricker, & Farchione, 1998; Guilmette, Hart, & Giuliano, 1993;
Iverson & Franzen, 1998; Mittenberg, Azrin, Millsaps, & Heilbronner, 1993), often display
unusual error patterns on neuropsychological tests (Benton & Spreen, 1961; Osimani, Alon,
Berger, & Abarbanel, 1997), produce more believable results on symptom checklists than on
clinical tests (Martin, Hayes, & Gouvier, 1996), and perform worse on more obvious neu-
ropsychological tasks than subtle ones (Bernard, McGrath, & Houston, 1996).
Despite limitations to their direct generalizability to clinical practice, simulated malin-
gering experiments have contributed to the development of new measures to detect malin-
gering (Davis, King, Bloodworth, Spring, & Klebe, 1997; Schagen, Schmand, de Sterke, &
Lindeboom, 1997; Tombaugh, 1997), and have suggested the use of cut-off scores (Arnett,
Branham, & Hiscock, 1994; Iverson, 1995; Mittenberg, Theroux-Fichera, Zielinski, &
Heilbronner, 1995) that inform practitioners and help them to detect “real world” malin-
gering. There remain, however, methodological issues in simulated malingering studies which
require standardization, and several variables whose impact on malingering behavior have not
yet been investigated.
Participants in simulated malingering studies are often given a role to play during the
assessment. The description of the role may include the motive of the participant to fake
a head injury. The typical motive is a hypothetical sum of money from a personal injury
settlement, the amount of which has been demonstrated to be unimportant (Bernard, 1990;
Martin, Bolter, Todd, Gouvier, & Niccolls, 1993). Alternately, several studies have used an
“avoiding blame” motive in which participants were instructed to perform on tests in order
to avoid “serious trouble” rather than gain compensation (Iverson, 1995; Iverson, Franzen, &
McCracken, 1994); however, these studies did not employ a compensation group with which
to compare their results.
A comparison of motivations is important as it has been shown that the scripts given to
participants in simulated malingering experiments affect the manner in which the participants
malinger (Arnett et al., 1995). Indeed, in clinical practice, the motivations for malingering
head injury are myriad and if litigation scenarios can be considered analogous to experimental
scripts, how different motivations affect neuropsychological test performance must be inves-
tigated. In non-experimental malingering studies, it has been shown that litigants perform
more poorly on neuropsychological tests than similarly or more severely injured non-litigants
(Binder & Willis, 1991; Lee, Loring, & Martin, 1992; Meyers & Volbrecht, 1998). Determin-
ing patterns of performance based on the type of secondary gain available to the participant
or patient may ultimately be helpful in identifying malingering in clinical settings.
Participants in simulated malingering studies may also be given “coaching” instructions
on how to fake a believable head injury. However, simulated malingering research has not
K. Erdal/Archives of Clinical Neuropsychology 19 (2004) 73–88
employed terminology, such as “coaching,” in a consistent manner across studies, leaving
unanswered questions about what should be included in a coaching manipulation. These in-
consistencies may have obfuscated findings in several experiments.
“Coaching” has been construed as aiding participants (or patients) in their attempts to per-
form on neuropsychological tests as if they are head injured when they are not, or as if they
are more severely head injured than they are. Coaching has been demonstrated to temper fla-
affix what might be considered a “warning” addendum to the instructions (i.e., “do not appear
too obvious in your attempts or you will be suspected of faking”; “there are ways to detect
faking on these tests”) (Arnett et al., 1995; Inman, Vickery, Lamb, Edwards, & Smith, 1998;
Johnson & Lesniak-Karpiak, 1997; Killgore & DellaPietra, 2000; McKinzey, Podd, Krehbiel,
Mensch, & Trombka, 1997; Rose et al., 1995; Rose et al., 1998; Slick, Hopp, Strauss, &
may not engender the same type of malingering performance. Indeed, Johnson and Lesniak-
Karpiak (1997) and Suhr and Gunstad (2000) found that adding an explicit “warning” state-
ment about malingering detection to their coached condition (which entailed a description of
providing test-taking strategies, and these two variables should be separated and compared.
1.3. Knowledge of neuropsychology
A comprehensive knowledge of neuropsychology and the effects of head injury cannot be
adequately “coached” in a short experimental vignette, although coaching provides specific
information toward the goal of impaired neuropsychological test performance. Knowledge
about head injury can range from that of the naive but coached participant to, presumably, that
of the professionals who work with head-injured patients. However, it is unclear which group
would provide more realistic neuropsychological test performance when asked to malinger a
Arnett et al. (1995) found that medical students performed more poorly on the 15-Item
Test (FIT) than college students when asked to malinger a head injury. Hayward, Hall, Hunt,
and Zubrick (1987) found that registered nurses who worked with brain injured patients per-
formed more poorly overall on neuropsychological tests than the patients themselves when
asked to malinger their patients’ performance. And Schwartz, Gramling, Kerr, and Morin
Memory Scale (WMS) than attorneys asked to malinger, the attorneys more closely approxi-
mating the head-injured group’s performance.
K. Erdal / Archives of Clinical Neuropsychology 19 (2004) 73–88
These findings suggest that knowledge of neuropsychology may not be sufficient (nor even
desirable) when attempting to malinger a head injury. Indeed, professionals who work with
brain-injured patients may, in fact, “know too much.” That is, they may draw from salient ex-
periences with moderately–severely brain-injured patients’ behavior and neuropsychological
test performance when asked to duplicate head-injured behavior, consequently exaggerating
their portrayal of the impact of a head injury.
Study participants’ pre-experimental levels of knowledge about head injury sequelae have
not always been assessed in simulated malingering experiments, which leads to additional
questions about how participants, typically undergraduates, should be selected for simulated
1.4. Current study
The current study was a simulated malingering experiment which compared three types of
motivation given to the participants in the experimental vignettes (no motivation given, com-
pensation, avoid blame) and three levels of a coaching manipulation (no coaching, coaching
post-concussive symptoms, coaching symptoms and warning about malingering detection)
in two groups of undergraduate students (introductory psychology, advanced neuroscience).
the mild head injury asked of them would be the introductory psychology students who were
coached and warned. As there was little research to guide hypotheses about given motivation,
the motivation manipulation was considered to be exploratory.
One hundred and forty-four students from a liberal arts college were recruited from two
populations; those who had taken introductory psychology but had not taken neuroscience
(n = 108), and advanced neuroscience students who had taken introductory psychology,
probability and statistics, research design, neuroscience, and neuropsychology (n = 36).
From the introductory psychology group, 15 students’ data were excluded due to having a
neurologicalillness(n = 2)orreportinglossofconsciousnessinthelast5years(n = 13).Two
students’ data were excluded due to reporting in a post-experimental manipulation check that
ing loss of consciousness in the last 5 years, leaving 34 (8 male and 26 female) participants.
The participants were paid $5 for their participation.
Each participant was randomly assigned to 1 of 10 conditions (one control and nine exper-
imental conditions). They read their malingering instructions (see Appendices A–C) which
K. Erdal/Archives of Clinical Neuropsychology 19 (2004) 73–88
were adapted from Arnett et al. (1995), Rees, Tombaugh, Gansler, and Moczynski (1998),
Rose et al. (1995), Rose et al. (1998), and Tombaugh (1997), paraphrased them, and then
gave informed consent. The participants were then administered a one hour battery of neu-
ropsychological tests, including two tests of malingering. Following the testing, the partici-
pants were administered a post-experimental manipulation check which, on a 5-point scale,
assessed overall effort in malingering performance and confidence in achieving the desired
result. Confidence in their performance on each individual test was also evaluated by asking
whether or not the participant believed she/he performed “within the range” of a head-injured
2.3.1. Rey’s FIT
tells the patient that she/he will need to memorize 15 different items, making the task appear
very difficult. In fact, the 15 items are presented in five rows which all but the most severely
impaired patients recall easily (i.e., A B C). A reliability coefficient of .88 has been reported
(Paul, Franzen, Cohen, & Fremouw, 1992). Cut-off scores of 7 or fewer (Lee et al., 1992),
8 or fewer (Bernard & Fowler, 1990; Schretlen, Brandt, Krafft, & Van Gorp, 1991), 9 or
fewer (Greiffenstein, Baker, & Gola, 1996), and 11 (Hiscock et al., 1994) items recalled have
been suggested to determine incomplete effort. The accuracy variables of number of items
recalled and number of items recalled in the correct positions were analyzed, in addition to
the qualitative variables of number of new items added during recall, number of items rotated
during recall, and number of perseverative responses.
2.3.2. Dot Counting Test (DCT)
The DCT is a test of dissimulation which presents stimuli of different difficulty levels in
a random fashion to assess whether the patient’s responses and errors are associated with the
task difficulty (Rey, 1941). The patient is shown two sets of six cards with varying numbers
of dots on them and is timed while she/he counts the dots. The cooperative patient’s time
pattern will increase as the number of dots increases. The first set of six cards have the dots
randomly placed on the cards (ungrouped) while the second set have the dots grouped, which
enable them to be counted more easily. Accuracy variables included number of grouped and
ungrouped cards correct (each out of 6), and ungrouped and grouped pattern (scored as 0:
times not in increasing order and 1: times in increasing order). The qualitative variables of
ungrouped and grouped total time taken for the cards were also analyzed.
The data were analyzed as a 2 Student Group (introductorypsychology, advanced
neuroscience)×3Motivations(nomotivationgiven, compensation, avoidblame)×3Coach-
ing of malingering detection) design.