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.