Summaries per article with Deception in Clinical Settings at University of Groningen 21/22

What are some important features of deception?

Individuals can have different motivates for deception at different times. A few important features about deception need to be kept in mind:

• Deception is a multidimensional construct that manifests differently across situations and settings.
• Deception is not taxonic - it is a dimensional construct that can change in direction and intensity.
• Deception is frequently adaptive.
• Individuals who deceive are not always aware of their motives for the deception.

What conceptual issues exist regarding feigning and related response styles?

• Individual’s motivations need to be carefully considered. Factitious disorders are usually viewed as existing on a continuum, and symptoms of malingering and factitious disorder can be difficult to disentangle.
• Isolated test results cannot be equated with a classification of feigning or malingering. Clinicians should use a multimodal approach that integrates information from behavioral observations, health history, criminal history, and objective psychological testing.
• Behaviors associated with malingering are not taxonic.
• There can be multiple determinants of motivations related to feigning and deceptive behaviors. Behaviors can span more than one explanatory model.
• Clinicians should use empirically validated terms.

Which types of malingering can be distinguished?

Resnick, West, and Payne subtyped malingering by the level of fabrication and exaggeration and distinguished three types of malingering:

• False imputation: symptoms are attributed to an etiologically unrelated cause.
• Partial malingering: exaggerating symptoms that individuals do not longer have.
• Full malingering: intentionally fabricating and exaggeration of symptoms for external incentives.

In which ways can deception be manifested as part of psychopathology?

Many clinicians think that any form of deception is an indicator of malingering, even though several DSM diagnoses include deception as an important aspect. There is also a difference between syndromes in which deception is planned and voluntary, and syndromes where deception is much less under control of the patient. In the following section you find an overview of disorders associated with various types of deception.

What are disruptive, impulse-control, and conduct disorders?

Oppositional Defiant Disorder (ODD) and Conduct Disorders (CD), diagnosed during childhood, are seen as precursors of developing more antisocial behavior later on in life. ODD and CD interfere with the development of positive family and peer relationships. In both disorders, deceitfulness is a core part of the diagnostic criteria. Researchers have highlighted that early engagement in conduct problems which are less severe, like lying, often develop more severe types of violent behavior in adulthood. In both ODD and CD, the deception is conscious as well as voluntary.

What is reactive attachment disorder?

Reactive Attachment Disorder (RAD) is defined by the DSM as a developmentally inappropriate social relatedness in most contexts, starting before the age of 5. The disorder is associated with much pathological care. It is a distortion in the early attachment, because of which the child often shows sociopathic behavior, including deception. Adolescents and adults who have a history of attachment problems are at higher risk of developing antisocial behaviors like cheating, lying and vandalism. Clinicians should pay attention to early home environments in order to be able to make a distinction between ODD, CD and RAD. Children with RAD try to overcome the abuse they experienced during their childhood through the use of superficial charm and manipulation.

What is a factitious disorder imposed on self?

Factitious Disorder (FD) is described as intentionally producing or feigning grossly exaggerated or false psychological or physical symptoms motivated by assuming the sick role. The presence of external motivation excludes this diagnosis. The symptoms can become apparent because they only present when the individual is observed, there is an atypical or dramatic presentation of the symptoms, covert use of substances etc. The presentation of the symptoms vary according to the disorder that is feigned, and a wide range of symptoms have been suggested to be associated with FD. Unfortunately, patients with FD are most often unwilling to cooperate with diagnostic procedures, which makes it difficult to effectively diagnose the disorder.

What is a factitious disorder imposed by another?

Factitious Disorder imposed by another (FDIA) is a variant of factitious disorder in which caregivers fabricate, exaggerate or make up physical or psychological symptoms in others, most often their children. When there is evidence suggesting the illness of a child is caused by a parent, a distinction has to be made between illness because of neglect and illness because of purposeful efforts to fabricate or induce a disorder. It is still unclear why people develop FDIA, but some explanatory models suggest motivations.

• The pathogenic model suggests over-attachment with the child or a rigid, defensive style.
• The criminological model suggests psychopathy and previous criminal convictions as explanations.
• Motivations of financial gain or attempts to resolve family conflict are presented by the adaptational model.

What role does deception play in a substance abuse disorder?

Substance abuse (SA) is often the cause of frequent lying, minimizing and denying in order to hide and be able to continue the abuse. De DSM states that in order to be diagnosed with SA, a great amount of time must be spent on obtaining, using, hiding and recovering from substance abuse, and deception is used to conceal these behaviors. The different explanatory models also have different explanations for developing these behaviors. Awareness for all kinds of reasons to deceive is necessary when dealing with SA. Multiple motivations are applicable.

• The pathogenic model may partially apply to people who are depending on highly addictive drugs
• The criminological model fits a broader pattern of antisocial behavior.
• The adaptational model may explain how substance abusers cope with adversarial circumstances, like getting medication for simulated pain when the actual problem is an Axis II disorder.

What role does deception play in eating disorders?

Eating Disorders like anorexia and bulimia include several deceptive manners in order to enable obsessive and compulsive behavior regarding their weight and body image. In these disorders, deception is often used to maintain having a feeling of control. In these cases, family deceptiveness is often identified as a factor in the etiology.

What are paraphilias?

Sexual abuse and Paraphilias are, according to the DSM, sexual deviations or perversions with behaviors or sexual urges focusing on unusual objects, activities or situations: in short, maladapted sexual behavior. These behaviors are deviant and illegal, and therefore may lead to imprisoning. Defensiveness, minimization and lying are key features of paraphilias and sexual abuse. Individuals may also develop cognitive distortions, which may present characteristic patterns of thinking that are potentially less voluntary. There are several motivations for deception among sexual offenders. They may use deceptive techniques regarding victims, but also to avoid being sentenced. Some people have suffered from abuse themselves and because of that have been unable to develop appropriate social skills and the ability to form age-appropriate interpersonal relationships.

What are personality disorders?

Personality Disorders and Psychopathy. People with a personality disorder show chronic, maladaptive patterns of thoughts and behaviors. They have a tendency to lie and behave in deceptive manners, which is most obvious in the antisocial personality disorder (APD). Other Axis II disorders like borderline also contain deception as an important feature. Psychopathy is a syndrome associated with the APD. It is a collection of behavioral and personality traits in conjunction with antisocial behavior. It seems that some psychopaths are excellent liars, but nevertheless most psychopaths are no more effective than other offenders at malingering. Psychopathy is unrelated to malingering, and using it as a criteria would lead to high levels of misdiagnoses. Psychopathy is related to deception, but is not a symptom or predictor for malingering.

Which other syndromes are related to deception?

What is parental alienation syndrome?

Child Custody and Parental Alienation Syndrome (PAS) occurs in custody cases in which a parent tries to maximize his/her own qualities and likeability, and minimize everything that’s positive about the other parent and make him/her appear less fit. Defensiveness is a regular feature of custody cases. PAS is a controversial, quite unaccepted clinical construct. It occurs when the dominant parent pressures the child to choose his/her side, and the child can deceive by complying with these expectations. It can also be the dominant parent lying about the other parent to limit access. Unfortunately, the validity of PAS remains far from settled.

What is false-memory syndrome?

False-Memory Syndrome focuses on the degree to which the trauma-based memories remain present in the absence of any objective evidence and the degree to which these memories define the individual’s life, leading to an inability to handle adult responsibilities. Such repressed memories have been the subject of several lawsuits. Clinicians should continue to consider the possibilities when dealing with sudden-onset memories, including potential for malingering and factitious disorder.

What is chronic fatigue syndrome?

Chronic Fatigue Syndrome (CFS) is characterized by exhaustion and extreme fatigue which makes everyday tasks extremely difficult to accomplish. There are many mental health symptoms that can co-occur with CFS, including malingering and factitious disorder. Many researchers warn of the association of malingering with CFS, because it can create unhealthy mistrust between patients and doctors. Because of the possible incentives, deception is definitely possible but clinicians should be careful with their judgement.

Which models can be used to decide whether deception is voluntary or not?

It is very difficult to decide whether deception is voluntary or not. In order to help make this decision, two models can be used.

• The threshold model functions as a screen for identifying potential cases of dissimulation that require further evaluation. The criteria are low in order to minimize missing individuals engaged in a specific response style.
• The clinician-decision model represents a definite conclusion about the presence of a specific response style or general deception. A definitive conclusion with this model cannot be reached without substantial evidence to support it.

What is Munchausen’s syndrome?

In 1951, Asher first labeled adult patients who present for treatment of fabricated symptoms with Munchausen’s syndrome. These people are also referred to as hospital addicts, since they continuously seek medical help and services. They do so even when they face serious risks by undergoing these (unnecessary) procedures. The reason for their behavior would be getting emotional gratification from their deceptive relationships with their doctors.

What is Munchausen by proxy syndrome?

Munchausen by Proxy Syndrome (MBP) is a form of child abuse in which a parent (usually the mother) intentionally fabricates symptoms of illness in a child, or induces the symptoms the child already suffers from. Most of the time, the fabricated or induced symptoms are consistent with life-threatening and/or chronic disorders. Parents who do this to their child are usually looking for rewards in the form of attention and support provided by family, friends and society. They want others to see them as heroes because of the way they handle the seriousness of their child’s illness.

How prevalent is Munchausen by proxy syndrome?

Because many physicians do not include the diagnosis of MBP in their discharge summaries, there is a substantial underestimate of the prevalence of the disorder. Also, only the worst cases are mentioned in saved records. There is quite a long period of time between the onset of symptoms and the diagnosis, and the diagnosis itself can take up to 6 to 15 months.

How does DSM-IV define factitious disorder?

MBP is registered in DSM-IV as factitious disorder by proxy. The disorder is defined as intentionally feigning or producing physical or psychological symptoms in another person who is under the individual’s care, with the aim of assuming the sick role. There are no external rewards present for the behavior, such as financial gain. Most of the time, the diagnosis is derived from a very lengthy process of elimination of other possible explanations for the symptoms.

What is the difference between pediatric condition falsification and factitious disorder by proxy?

This changed when Ayoub proposed a model that should improve diagnostic accuracy. A few years later, in 2002, the model was presented as a position paper by the American Professional Society on the Abuse of Children (APSAC). This model divides MBP into two functional components. The first component is labeled pediatric condition falsification (PCF), which acknowledges the falsification of the medical presentation of the child. It describes the form of child abuse in which a parent or caregiver intentionally feigns symptoms in a child. The second component is called factitious disorder by proxy (FDP). This component emphasizes the specific psychiatric diagnosis of the parent, and gives this as motivation for the behavior (missing in the original diagnosis of PCF).

What are the advantages of Ayoub’s model?

The model allows doctors to identify PCF more quickly and thereby protect the child in an earlier stage. Also, this makes it possible to leave the determination of the perpetrator’s motivation and psychopathology to qualified mental health professionals. Furthermore, this way the judicial system can be included at an earlier point in the investigation. Psychologists can provide the court with information needed for effective intervention with the family and relevant information regarding treatment, instead of using the court to ensure compliance and collaboration by the family members. All in all, using this model makes it easier for epidemiologists to more accurately identify the extent of child abuse as a result of factitious symptom presentation.

What increases the risk of misdiagnosis of MBP?

When parents deliberately manipulate medical information, the authors believe that MBP must always be considered. There is however always the risk of misdiagnosis and the following situations can increase the risk of misdiagnosing MBP:

• Overacting of symptoms by a parent whose child is recovering from a documented health crisis (for example with prematurity).
• The description of extreme symptoms which are not present at the time of the medical examination because of variability in the child’s authentic symptoms (like with asthma).
• A parent who is overanxious and therefore appears to access excessive care for the child, but is non-abusive.
• Conscious exaggeration of symptoms by the parent without any intention to deceive, but with the purpose of drawing attention to the original symptom.
• The child or parent is malingering, there is no factitious disorder.
• The child suffers from a medical disorder that has eluded detection and may be rare.
• The child’s illness threatens to become worse because of noncompliance by the parent with the prescribed medical treatment.
• The parent does fabricate symptoms and feigns the child’s illness, but shows no MBP motivation (for instance because they are suffering from a psychotic disorder and are experiencing hallucinations/delusions).
• Someone deliberately levels a false MBP accusation because of personal conflict (for example in a high-conflict divorce).

How can MBP be detected?

• Doctors and other medical staff may get suspicious and recognize the potential of a MBP case when a disproportionate number of hospitalizations and physician visits occurs, or when the symptoms reported are highly unusual or inconsistent.
• There is more medical staff to observe the child in case of hospitalization, and in combination with the collection of laboratory specimens for analysis, mother perpetrators get discovered because the specimen appears to be tampered with.
• It is likely that the amount of active induction of symptoms grows in the hospital environment, because the mother wants to convince the doctor of the necessity of more tests and procedures.
• The educational system may also be the referral source, because they detect an inordinate number of school days missed because of illness, medical procedures and doctor’s visits.
• Finally, when the medical staff gets suspicious about the role of the mother perpetrator regarding the symptoms, doctors may choose to use covert surveillance through video-taping in the hospital setting to obtain evidence.

What are the characteristics of mother perpetrators?

They appear to be deceptive and manipulative about many aspects of their lives. Many details about their history in life are fabricated. They often have an education in or experience with the medical field. They insist on managing the child’s care, especially medications and medical equipment. They often suffer from post-traumatic stress syndrome or a personality disorder (especially dependent, borderline and antisocial) and in many cases they are survivors of childhood abuse themselves. They often show unusually calm behavior in the face of crises related to the child’s medical status. There are very few reported cases regarding men perpetrators.

Who are the victims of MBP?

Boys and girls are equally victims, but there are more preverbal than verbal child-victims. The average age is approximately between 3 and 4 years old. The most common (feigned) symptoms are seizures, apnea, bleeding, unconsciousness, vomiting, diarrhea, lethargy and fever. There are some consistent traits in families where MBP is present. They often lost a sibling due to an unverified or unexplained illness. Also, family history of illness behavior or family interactions that respond to illness with attention are common. In some cases there is a distant or abusive marital relationship, and a father who is described as aloof, uninvolved in the medical aspects of their children’s lives and emotionally detached. Even so, fathers are often shocked when they are faced with the allegations of MBP abuse.

How can a case of MBP be handled?

When managing a MBP case, a multidisciplinary team is necessary. These are often led by child protection teams. The investigations of cases of MBP abuse usually occur in hospitals, so that when symptoms continue unabated in the absence of the mother, the child is still in a medical setting and provided with appropriate assistance. The diagnostic model used (as discussed earlier) first examines the available medical evidence and then investigates the psychological question regarding the family members involved.

Why are victims of MBP often placed out of the home?

When the (shocked) father of the child-victim isn’t able to be protective, out of home placement is necessary for the child’s safety. When family members offer to take care of the child, psychological evaluations are necessary. This is because in some cases there is a cycle of abuse, like with sexual abuse histories. Although most of the intentions by family members are genuine, neutral and non-relative placements are more safe. When victims enter foster care, thorough medical assessments are needed. All medications should be reviewed and, if necessary, replaced. The foster parents need to take pictures of the child when it enters their home, and keep a daily log of its behavior (including food intake, behavior and sleeping patterns). A physician should see the child on a regular basis, partly because a child can be a victim of MBP, but at the same time suffer from legitimate illness.

How can the relationship between the perpetrator and the victim be re-established?

Contact between mother and child is not recommended before the mother started treatment and, at least partially, acknowledges the abuse. Extended family contact should always be supervised, just like meetings with the mother later on. Supervisors should be trained to recognize harmful behavior. No food or drinks should be served during the visits. When the mother is making progress, the supervisors may be replaced by video-taped contact.

Which kind of mother perpetrators can be identified?

Libow and Schreier identified three kinds of mother perpetrators. The ‘help seekers’ often have the purpose of obtaining help for their feelings of inadequacy as parents. They often show willingness to give up their deceptive behavior once help has been offered. In contrast, the ‘doctor addicts’ and ‘active inducers’ are motivated by some sort of emotional gratification gained from their deceptive relationships with the physician.

How can mother perpetrators be treated?

Most mother perpetrators leave treatment before finishing it and a lot continue their deceptive behavior with their therapist. Also, they often suffer from personality disorders which are difficult to treat in itself. The most well-known treatment plan can be divided in three stages:

1. The therapeutic process needs to be separated from any legal involvement, to be able to establish trust and gain insight into the patient's secret thought processes. The main goals of the first stage are establishing boundaries, strengthening coping skills, dealing with the many crises these women face, and maintaining trust between therapist and patient. Techniques used are videotaping, journaling, family photo reviews and teaching relaxation and mindfulness techniques. At the end of this stage, the patient should be able to acknowledge, at least to some extent, the abuse she has perpetrated.
2. Developing empathy for the child-victim. The traumatic memories of the mother from her own childhood will surface, and the patient will become more psychologically available to engage in appropriate therapeutic work on these issues. At the end of this stage, the mother should have established her own identity, attained vocational goals to become self-supporting, and developed a social support system.
3. Much is unknown about the final treatment stage, because most perpetrators don’t complete their treatment plan. In some known cases, the psychological evaluation was updated and completed, which confirmed no further need for treatment. Sometimes these mothers received up to 5 years of therapy.

How can the other family members be treated?

The treatment of other family members should occur simultaneously with the treatment of the mother. There should be coordination between the therapists of all of those involved. The father should engage in individual therapy to process the awareness of the wrongdoing to his child by its mother.

How can the child be treated?

Because of the age of the victim by which the MBP abuse usually appears and is discovered, the child generally internalizes the effects of victimization at a preverbal level of psychological development. The most well-known intervention to treat this is nondirective play therapy. This therapy allows children to work through the abusive parent-child dynamics they have experienced and to adjust to the dynamics of the new relationship being developed by the new caregivers.

What is the difference between feigning and malingering?

In the medical context, the term feigning is used more broadly than malingering, and includes exaggeration, magnification, or faking of symptoms. Feigning can include unawareness of behavior for the production of simulated symptoms without clear evidence of external gain. Malingering is a conscious choice to intentionally exaggerate or fabricate a medical or psychological condition for external gain. Feigned presentations can be classified in three general domains, namely physical (somatic), cognitive, and psychological (emotional). 

What types of malingering are there?

Three categories of malingering have been identified: 

• In pure malingering the person entirely fabricates a psychological or medical condition that does not exist and has never existed. 

• In partial malingering the person is exaggerating symptoms of a condition that actually exists. 

• False imputation refers to an individual ascribing symptoms to an unrelated cause. Here, the symptoms are genuine, only the source of the symptoms is in question.

Which differential diagnoses exist with regards to malingering?

When malingering is a clinical consideration, the following five conditions should be considered in the differential diagnosis:

• Undetected physical pathology. Any person with unexplained physical complaints may actually have an illness that is not detected during an initial evaluation (or even with subsequent testing). 

• Somatization disorder. This refers to a pattern of recurring polysymptomatic somatic complaints resulting in medical treatment or impaired daily functioning. 

• Hypochondriasis. This refers to the preoccupation with the fear of having, or the idea that a person has, a serious disease based on the person’s misinterpretation of bodily symptoms. 

• Pain disorder (pain disorder with related psychological factors or pain disorder exclusively related to psychological factors).

• Factitious disorder with predominantly physical signs and symptoms. This refers to a category of physical or psychological symptoms that are intentionally produced in order to assume the sick role, which the patient finds very gratifying. 

How common are feigned medical presentations?

Almost any medical illness can be feigned or malingered. Some types of medical problems are more likely to be feigned or malingered than others, namely personal injury, disability, criminal injury, or medical matters. Within medical cases there are high percentages of probable malingering and symptom exaggeration. Malingering is often supported by evidence in severity or pattern of cognitive impairment inconsistent with the condition. There are also discrepancies among records, self-report, and observed behavior, and implausible self-reported symptoms in interviews. Finally there were implausible changes of test scores across repeated examinations and validity scales on objective personality tests. 

How prevalent is physical feigning and malingering?

The prevalence rates of physical feigning and malingering vary and studies often have very few participants. To determine the base rates for physical medical malingering multiple factors are involved, such as the clinical setting, the individual practitioner, the practitioner's specialty, whether psychological measures are added to physical examination, and clinical patients versus examinees seeking compensation. The two discrepancies in self-presentation most frequently mentioned as suggestive of malingering involved muscular weakness in the examinations not seen in other personal activities and claimed disablement disproportionate to the objective physical findings. 

How prevalent is cognitive feigning and malingering?

The most alleged neurocognitive impairment in a litigation setting is traumatic brain injury, with a combined rate of probable and definite malingered neurocognitive dysfunction of 54%. Examinations of traumatic brain injury in compensation-seeking circumstances should be looked at carefully, with attention paid to premorbid and postinjury psychological status, insufficient effort, and symptom exaggeration. 

How prevalent is psychological feigning and malingering?

Different feigning measures and detection strategies should be used for each different domain of psychological feigning (malingered psychosis, malingered PTSD, feigned psychological impairment). 

How can medical feigning and malingering be detected?

All cases of medical examination that include a significant incentive should include the services of a psychologist or a neuropsychologist to provide assessment of feigning/malingering. Motivation needs to be evaluated. Malingerers may complain of a mental, behavioral, or physical disorder (or all). The possibility of avoiding responsibility and/or getting a monetary award increases the likelihood of exaggeration and/or malingering. Nonspecific symptoms that are difficult to verify are often overrepresented (e.g. headache, lower back pain, vertigo). 

• There are no direct measurements of physical malingering available. Physicians will have to use fairly simple tests while performing a physical examination to detect symptom exaggeration/malingering. 

• Performance validity tests are very important when an examinee is claiming cognitive/neuropsychological deficits in a compensation-seeking context. Practitioners have multiple, well-validated procedures suitable for detection of such deficits, such as the Test of Memory Malingering, the Medical Symptom Validity Test, and the Word Memory Test. 

• The two most important measures for feigned mental disorders are the Miller Forensic Assessment of Symptoms Test and the second edition of the Structured Interview of Reported Symptoms. 

Performance validity tests (PVT) are objective measures that evaluate the validity of someone's execution of a performance-based test. These measures are not very sensitive to problems that occur because someone does not have the ability to perform, but instead are sensitive to noncredible effort.

Do noncredible presentations happen in children?

It appears that children are capable of deception under the right circumstances. They get increasingly deceptive as they develop the abilities that are necessary for it throughout childhood and adolescence. These noncredible presentations occur both consciously and unconsciously, and both with and without the influence of parents. Children and adolescents appear to be able to fake both psychiatric and physical difficulties, but also cognitive problems.

Noncredible responding occurs more in relation to a number of pediatric conditions and settings. The most noncredible effort can be seen in children with persistent problems after they have gotten a light head injury. We do not specifically know about other conditions and settings because they have not been studied in detail.

Why is subjective judgment inadequate for detecting noncredible data?

Noncredible effort can occur for many reasons. One of these reasons is deception, but others include separation anxiety, hunger or fatigue. In order for us to determine which steps to take we need to figure out the underlying motivation of children making the noncredible effort. However, to do this, invalid responses need to be recognized as invalid at first. Historically many clinicians rely on subjective judgment to do this when it comes to children. However, errors occur for many reasons and so an objective instrument is needed to improve clinical decision making. Adult practitioners have already adopted the use of PVTs, seeing them as a supplement to the subjective judgement. However, many child practitioners have not. This is mainly because they did not have access to any tools that objectively determine whether children are making a noncredible effort. Today, more PVTs for children have been developed.

Do validity test results matter?

Are there clinical implications of ability-based test interpretation?

PVT failure is associated with worse performance on different types of neuropsychological tests for both adults and children. This means that a noncredible effort can have a big effect on other test results as well. This means that if we do not suspect or recognize noncredible effort, we could interpret test results wrong, make inaccurate diagnoses or provide people with ineffective treatment. This could seriously harm both adults and children.

Are there clinical implications of the interpretation of self-reported data?

Many studies suggest that if children perform bad on PVTs, they are also more likely to misrepresent themselves when filling in self-report measures. Thus, the results of the PVT of a child can relate a lot to how they self-report their emotional, cognitive and health-related complains.

What are the broader implications of using or not using PVTs?

Using PVTs could give us a completely different understanding of individual cases, but there are also broader implications.

• Firstly, when we do not use PVTs in studies about children, we need to remain skeptical about all the things they conclude.
• Secondly, on a fundamental level we need to test the idea that all children put in adequate effort if they go through cognitive testing. This because the traditional belief that performance tests measure ability seems to not be true. Instead, performance tests also reflect different amounts of effort children put in.
• Thirdly, there are public health implications. If children that show noncredible performance are not found through testing, they use up many healthcare and educational resources.
• Finally, not finding noncredibly performing children creates unnecessary costs to society. Namely, the costs of malingered disability is extremely high. 

What are secondary gains/external incentives and primary gains/internal incentives?

External incentives or secondary gains are advantages that someone could gain from behaving in a certain way. This means that when an external incentive or secondary gain is present, someone often actively and consciously chooses to act in a certain manner. There are two types of these gains. The first one is material-legal: substantial tangible rewards such as financial compensation, disability benefit or getting out of formal duties or criminal charges. Psychosocial gains are any interpersonal, social or emotional benefit for a person.

Primary gains or internal incentives are rewards that are less tangible and instead are more internal. These are often sought out less consciously, but instead are strived towards unconsciously. Examples of these gains are attention from others, or avoiding negative feelings such as stress.

Can school refusal influence noncredible presentation?

School refusal can influence noncredible presentation, especially in children. When they are struggling academically, are having a hard time adjusting or experience other struggles at school they may refuse to go to school. When a child is showing noncredible presentation a clinician must always evaluate whether it is because of school refusal behavior. This is especially the case when a child is under great academic stress due to adjusting to a new setting or the demands of a certain grade they are in.

Can social demands influence noncredible presentation?

Chidlren and adolescents have to meet a lot of social demands. These factors include wanting to gain attention from others, or wanting to avoid stressful situations. One of the biggest influences on youth is bullying. A child may start to show symptoms or noncredible presentations due to stressful social situations.

Can sports influence noncredible presentation?

Often, young people involved in high levels of sports do want to get back out there after an injury. However, a small number present noncredibly because they hope that a clinician tells them they can't get back to the sport. This often happens if a child or adolescent does not openly want to admit they do not want to practice the sport anymore. They are afraid they can't perform at their old level or are experiencing pressure to keep going from someone else, like a parent.

Can primary psychological disorders influence noncredible presentation?

If a child performs noncredibly then a clinician should always consider a pre-existing or comorbid psychological disorder. For example, a child could suffer from somatic symptom disorder, where somatic complaints begin to interfere with daily functioning and the child is completely preoccupied with them. Another thing that could be present is an internalizing affective disorder such as anxiety or depression. A last disorder that may cause noncredible presentation is a conversion disorder, where motor or sensory functions of a child are altered, but these alterations do not match with any medical or neurological conditions. Psychological distress is 'converted' into a physical symptom.

Are there other factors that can contribute to noncredible performance?

There are other motivators for children to show noncredible clinical presentations or put in noncredible effort. These are:

• Family stressors. Examples are divorce, abuse, violence or financial strain.
• Iatrogenic factors. Iatrogenesis is when an examination or treatment causes a patient to believe they are more ill than they actually are. This means that when a patient believes they are ill, they also believe they should perform bad on certain measures and as a result do so. Additionally a doctor may tell a patient their symptoms may be due to a certain disorder, and as a result, the patient may internalize this and behave consistently with the diagnosis.
• A cry for help. When children are distressed they might not know how to ask for help or they may fear people may not help them if their symptoms are too 'minimal'.
• Noncompliant behavior. A child may show noncredible performance because they do not want to do what they are told.

How can we separate children's motives to show noncredible presentations?

• Establishing rapport. A clinician has to do this both with the family of the patient and the patient themselves. In doing so, the child may be less anxious and perform more credible or if the child does perform noncredibly, the clinician may make the space to openly discuss this. A clinician establishes rapport by being warm and nonjudgmental towards any concerns the patient and family may have. 
• Taking a very detailed history. A clinician has to take this history both from the patient and the family. This history should be about the behavior of the child throughout their life, their personality and any other things that stand out. To get as much detail as possible, a clinician should ask open ended questions and only use specific closed questions to identify details or clarify things.
• Conducting a detailed clinical interview. This interview must be done with open ended questions and can be unstructured to allow it to be a conversation. A patient's enjoyment of school and any problems they might have academically must be explored. Their social life must be mapped out as well.
• Using objective rating forms. This can help the clinciian to map out a child's emotional functioning, as well as behavioral functioning and behavior patterns at school. Both the parents and the child are often asked to fill out these forms.

Which types of polygraph test are there?

In America, polygraph tests are primarily used by government agencies and the criminal justice system. They are also used for civil cases and to combat insurance fraud. A polygraph is a device that amplifies certain physiological signals, such as blood pressure, palm sweating and respiration. Polygraph techniques are not objective, not standardized and they do not have norms. What the examiners do is look for physiological responses that are associated with lying based on how people respond to different types of questions. Three types of tests can be done with the polygraph:

• Employee screening tests. This test is usually a relevant-irrelevant test (RIT). Here, employees are asked relevant questions about their work behavior, mixed up with questions that are irrelevant for the job. When a relevant question about for example drug use elicits a more pronounced response, employers often confront the subject. The RIT assumes that truth tellers respond strongly to irrelevant questions and not so strongly to relevant questions, or at the same level to all relevant questions. It also assumes liars respond more strongly to the relevant questions.
• Guilty knowledge test (GKT). This is also known as the concealed information test. During this polygraph test, people are asked factual questions about whether they are or are not involved in a crime. The questions are multiple choice and contain one guilty answer alternative that only the guilty person would know next to the examiner. It assumes that innocent people respond the same to all GKT answer alternatives, but a guilty person would respond more strongly to the guilty alternative. An alternative to the GKT is the event-related potential (ERP) variant. These methods ensure someone responds to all items so rapidly they do not have time to employ countermeasures.
• Comparison question technique (CQT). This technique is most often used in real life and most likely to be made available to mental health clinicians. The clinician designs questions related to an incident that took place, that can only be answered with yes or know. Truth tellers will respond more strongly to control or comparison questions, whereas deceptive individuals will respond more strongly to the relevant questions. This is because truth tellers know they are telling the truth on the relevant questions about the crime, as they have not committed it. Thus, they fear lying on the control or comparison questions more. For deceptive individuals, the relevant questions pose more of a threat, as they are about a crime they have committed. This is why their responses will be bigger to the relevant questions, and less intense to the comparison questions. However, it is feared that that innocent individuals might also experience distress on the relevant questions when being falsely 'accused', thus the test is biased against the innocent. Another concern is that this test is very vulnerable to countermeasures, which are strategies that are deliberately adopted to change the outcome of the polygraph. These strategies can be found online by anyone.

What do people say about the accuracy of the CQT?

People within the polygraph profession insist that it is highly accurate. People a bit further from the profession however, believe that it is not standardized, objective or based upon a good theory. The accuracy levels of the CQT are often questioned by those outside the field.

Are there alternative methods to the polygraph?

There are alternative methods to the polygraph. However, these are not widely used. Examples are voice stress analysis or EEG. The reason they are not widely used is because they are not admissible in court as evidence.

What are the clinical applications of these tests?

Screening tests for employees are still widely used, as are control question tests. The latter one is often used in the case of sex crimes. Not only are they used for confessions, but they are also used to assess treatment success or check rule compliance. The control question tests are also used in possible child abuse cases. In the rapport, the examiner usually reports the allegations against a subject, what the questions asked were, and an explanation of what happened by the subject.

What are the different types of integrity testing?

Integrity testing is a type of testing where people fill out questionnaires that measures certain traits or behavioral tendencies that are associated with dishonesty or possible counterproductive behavior. These are often used for the screening of employees or personnel selection. There are two major categories of this preemployment screening, namely overt tests and personality oriented tests. Overt tests contain statements or questions that ask a person directly about how they feel about dishonesty or illegal activities. Personality oriented tests are tests that are 'veiled', they are used to predict counterproductivity rather than theft or dishonesty specifically and clearly.

Do integrity tests have good validity?

There are two types of validity that have to be good for integrity testing specifically. The first one is criterion-related validity. This type of validity is about whether integrity tests are doing what they are supposed to do; namely, identify those that are likely to engage in theft or counterproductive behaviors. This validity relates to whether a test is effective for the purpose that it was intended for. The second one is construct validity, which refers to whether the question actually measures the underlying psychological construct it wants to measure.

How do we measure criterion-related validity?

We measure criterion-related validity in two ways. The first one is self-report, for example when someone admits theft or counterproductive things like absenteeism. The second one is external criteria, for example documented days someone was late, broke something or terminations for wrongdoings like theft. This last measure has the problem that it is not sensitive; many counterproductive behaviors often go unnoticed or are not recorded.

How do integrity tests relate to basic personality traits?

Integrity tests relate to the Big Five: extraversion, neuroticism, agreeableness, conscientiousness and openness to experience. Conscientiousness appears to be the best predictor for all job related criteria. Extraversion appears especially important for job performance with jobs that involve a lot of social interaction. Openness to experience appears to be very important to how much people respond to job training, but not to job performance itself. Any personality traits related to dependability and trustworthiness appear to be very predictive of how well people do at their jobs.

However, integrity tests appear to go further than the Big Five. They measure an honesty factor that is not reflected in the Big Five through looking at fairness and sincerity. They also assess important aspects of self-control that are not included in the Big Five.

How does integrity relate to externalizing proneness?

Any trait that has to do with self-control stands opposite of externalizing psychopathology: addictive behaviors and impulsive-antisocial beahvior. Thus, scores on integrity tests reflect the variation that people show in externalizing vulnerability, or the variation in impulse control problems.

Are there any controversial aspects to integrity testing?

There are a few controversial aspects to integrity testing:

• Honest and dependable workers may be denied employment because they fail their integrity tests, or their scores fall below cut-off scores companies stick to for hiring. In other words, people that are not actually dishonest may be classified as such and thus be denied work. There is a problem with false positives.
• Integrity tests may be very vulnerable to people trying to fake being trustworthy. Thus, next to a problem with false positives, the integrity tests may also be vulnerable to false negatives due to people consciously deceiving.
• Integrity tests may also discriminate against protected groups. These protected groups, namely women, racial minorities or elderly people may possibly score higher on such tests by default, thus making it less likely they get hired.
• The questions asked on integrity tests may be an invasion of privacy of the respondent, especially the overt integrity tests, where direct questions about wrongdoings are asked.
• A related issue to the above one is that of informed consent. Often, when people apply for a job and they have to do an integrity test, informed consent is implied, but this must be balanced by the employers explaining why they have to.
• Integrity testing cannot be the primary basis for hiring or firing someone.

Are there other types of assessment?

Types of assessment that could be considered are gaming or VR approaches. These could be alternatives to self-report methods. An example of a possible computer approach is the Implicit Association Test (IAT). Another approach is to do tests of cognitive ability. A third option would be to add brain response measures into measures of integrity. The best option would be a multimethod approach in which brain response measures, self-report measures and beavhioral response variables are combined into one test of integrity.