Journal of Clinical Psychology, April 2007

Assessing the competency of mentally retarded individuals is one of the most challenging issues for the forensic psychologist. It is essential to assure that mentally retarded defendants have the ability to comprehend the legal proceedings and assist in their own defense; however, the fact that defendants are significantly limited intellectually certainly does not rule out the possibility that they may attempt to exaggerate their level of impairment during a forensic evaluation. The issue is complicated by the fact that mentally retarded defendants may well perform more poorly on malingering tests than do individuals of normal intelligence, even when making their best effort. For example, the Rey Memory Test (Rey, 1964) has been shown to be a useful tool in assessing malingering in criminal defendants (Heinze, 2003; Simon, 1994); however, studies have suggested that this test is not appropriate for the detection of malingering in mentally retarded defendants. For example, Goldberg and Miller (1986) found that 37.5% of mentally deficient patients on a mental retardation unit scored below the cutoff criteria for malingering while nearly 80% of mentally retarded patients in a recent study by Hurley and Deal (2006) would have been incorrectly classified as malingering using standard criteria. Hays, Emmons, and Stallings (2000) found that mentally retarded patients made significantly more qualitative errors than did general psychiatric patients. Hayes, Hale, and Gouvier (1997), in a study conducted at a state facility for the criminally insane, found that mentally retarded malingerers actually outperformed nonmalingering patients with mental retardation on three tests of malingering. They concluded that these three tests, the Dot Counting Test (Lezak, 1995), the Memory for Fifteen Items Test (i.e., Rey Memory Test), and the M-Test (Beaber, Marston, Michelli, & Mills, 1985) should not be used in the detection of malingering in mentally retarded defendants. The Test of Memory Malingering (TOMM; Tombaugh, 1996) was developed to provide psychologists with a tool to help them in discriminating between patients who have a bona fide memory impairment and malingerers. The TOMM is a 50-item visual recognition test that includes two learning trials and an optional retention trial. The participant is shown 50 simple line drawings for 3 s each during each of the two learning trials. Following each learning trial, the participant is shown 50 recognition panels, one at a time. Each panel contains one of the previously presented line drawings along with a drawing that the participant has never seen before. The participant is asked to point to the drawing that he or she has previously seen. Only the participants score on the second trial (i.e., Trial 2) is considered in making a determination of possible malingering. The Retention Trial can be administered 15 min after Trial 2. Since the test involves the presentation of a large number of visual stimuli, participants falsely make the assumption that the test is much more difficult than it actually is. Research data support Tombaughs (1996) assertion that malingerers assume that the test is quite difficult and thus perform poorly while the vast majority of nonmalingering patients put forth their best effort and do well. Tombaugh (1997) found that neurologically intact participants attained perfect scores on both Trial 2 and the Retention Trial; however, more significantly, he found that the TOMM is relatively insensitive to genuine memory impairment. Specifically, patients with cognitive impairment, aphasia, and traumatic brain injury were found to attain scores exceeding 97% accuracy on Trial 2 and the Retention Trial and rarely scored below 45 on either trial. Only a dementia group had a sizable number (27%) of participants score below 45, although their average scores were still above 45. Tombaugh (1996) recommended a cutoff score of 45 on Trial 2, as this led to the correct classification of 95% of all nondemented patients (91% of all patients) as nonmalingerers. Tombaugh (1996) indicated that the Retention Trial only needs to be administered if a participant scores below 45 on Trial 2; however, Greve and Bianchini (2006) strongly recommended administering the Retention Trial, unless another symptom validity test is administered.

Performance of Mentally Retarded Forensic Patients

Studies have found that patients with severe depression (Rees, Tombaugh, & Boulay, 2001; Yanez, Fremouw, Tennant, Strunk, & Coker, 2006), cognitive disorder associated with psychosis (Duncan, 2005), cognitive impairment (Teichner & Wagner, 2004), older adults with anxiety or depression (Ashendorf, Constantinou, & McCaffrey, 2004), and young children (Donders, 2005) are able to attain adequate scores on the TOMM. Only one study has assessed the utility of the TOMM with mentally retarded clients; Hurley and Deal (2006) administered the TOMM, along with three other instruments that have been used to assess malingering, to 39 patients residing in one of two residential facilities for individuals with mental retardation. The results suggested that the TOMM was not applicable to a mentally retarded population, as 41% of their participants fell below the cutoff for malingering on Trial 2 (the optional Retention Trial was not administered). The present study is the first to evaluate the utility of the TOMM with actual forensic inpatients who have been diagnosed as mentally retarded. A study by Gierok, Dickson, and Cole (2005) found that patients with pending legal charges exerted less effort on the TOMMthan those with no obvious secondary gain whileWeinborn, Orr,Woods, Conover, and Feix (2003) found that adjudicated forensic patients did significantly better than did patients still facing legal charges. Thus, a decision was made to include only patients who were no longer facing legal charges in an attempt to eliminate any external incentive to malinger. It was hypothesized that mildly retarded forensic patients, with no motivation to malinger, would attain passing scores on the TOMM.

Methods Participants
The subject pool consisted of 38 criminal defendants who were admitted to the Forensic Unit of the Arkansas State Hospital with an Axis II diagnosis of Mild Mental Retardation, over a 2-year period, for restoration of competency. All 38 defendants had been evaluated on an outpatient basis by state-certified forensic evaluators (usually a psychologist, but occasionally a psychiatrist). Following admission to the Forensic Unit, each of these defendants (now patients) were assigned to a treatment team consisting of a psychiatrist, a psychologist, a social worker, and the nursing staff. The role of the treatment team was to accurately assess the patients mental problems and then work toward restoration of competency, if this was possible. Since a diagnosis of mental retardation is extremely important not only with regard to the legal issues of competency and criminal responsibility but also to future discharge planning, a priority was placed on confirming this diagnosis. As part of this process, the social worker assigned to the case obtained relevant mental health records and interviewed one or more family members. School records were requested and reviewed when available. All patients were assigned to a variety of groups and a competency-restoration class. Input from group leaders was obtained during weekly treatment-team meetings. Nursing staff observed patients 24 hr a day and provided information regarding the patients level of functioning on the unit. Intellectual testing was considered an essential part of the diagnostic process; thus, the WAIS-III (Wechsler, 1997) was administered by a hospital psychologist if it was not included as part of the defendants outpatient evaluation. Each patients final diagnosis as well as opinions regarding competency to stand trial and/or criminal responsibility were determined at a staffing conducted by their respective treatment-teams within 10 months of admission, as required by Arkansas state law. Of the original subject pool of 38 defendants, 21 met the requirements for inclusion in this study; that is, a confirmed diagnosis of mild mental retardation and resolution of their criminal charges (Not Guilty by Reason of Insanity: n _ 19; Not Performance of Mentally Retarded Forensic Patients 341 Restorable: n _ 2). The 21 participants (17 males/4 females; 15 African American/6 Caucasian) ranged in age from 21 to 57 years (mean age_35.2). TheWAIS-III IQ scores of the participants ranged from 51 to 69 (M _ 60, SD _ 4.8). In addition to their Axis II diagnosis of Mild Mental Retardation, most (n_17) of the participants also had a major mental illness diagnosis on Axis I, with the vast majority of these (n _ 15) falling under the DSM-IV-TR category of Schizophrenia and Other Psychotic Disorders.

Procedure
Following adjudication of their charges, participants were assigned to a staff social worker for discharge planning, who then referred them to the present study. Each participant was subsequently assigned to a predoctoral psychology intern, blind to the purpose of the study, for administration of the TOMM. After obtaining informed consent, the TOMM was administered according to standard procedures in a testing room on the Forensic Participants scores on Trial 2 of the TOMM ranged from 43 to 50 (M_48.7, SD_1.9), while their scores on the Retention Trial ranged from 46 to 50 (M _ 49.4, SD _ 1.12). Only 1 participant scored below the cutoff for malingering recommended by Tombaugh Despite the small sample size, the results of this study provide convincing evidence that mildly retarded forensic patients can perform well on the TOMM. None of the participants scored below the accepted cutoff for malingering on both Trial 2 and the Retention Trial. Only 1 participant scored below the cutoff on Trial 2, but subsequently scored above the cutoff on the Retention Trial. What makes the results particularly striking is the fact that the majority of participants in this study were not only mentally retarded but also suffered from a major mental illness. Thus, the results suggest that the TOMM can be a used in assessing malingering in mildly retarded criminal defendants with little fear of obtaining false indications of malingering. Perhaps, just as importantly, the present findings provide validation for the use of the TOMM to help confirm malingering in defendants whose IQ test performances yield suspiciously low results. In other words, it is likely that many defendants who feign mental retardation will perform poorly on the TOMM due to the false assumption that intellectually impaired defendants will not do well on this test. Based on the present data, their poor performance can confidently be taken as a sign of malingering rather than as a concomitant of low IQ. The results of this study are not consistent with those obtained by Hurley and Deal (2006), who found that 41% of their sample of individuals with significant subaverage intellectual functioning scored below the cutoff for malingering. While the reasons for this are unclear, there are several possible explanations. First, while both studies used Unit. All participants were administered Trial 1, Trial 2, and the Retention Trial. During the 15-min interval between Trial 2 and the Retention Trial, the participants were administered the Object Assembly subtest of theWAIS-III. Following completion of testing, the TOMM was scored by the intern who administered the test.

Results
(1996) on Trial 2 while no participants scored below the cutoff on the Retention Trial. Thus, the specificity rate (i.e., percentage of participants correctly labeled as nonmalingerers) was 95.2% for Trial 2 and 100% for the Retention Trial. intellectually impaired participants, Hurley and Deals participants all resided in residential facilities for the mentally retarded whereas the participants in the present study were living in the community prior to their arrests. Thus, there may be some intrinsic differences in mentally impaired individuals who require residential care and those who have the skills to live in the community. In addition, it appears that level of motivation also may have been a factor. In both studies, participation was voluntary, and no compensation or rewards were offered; however, in the present study, participants were adjudicated defendants who had begun the process of planning for discharge from a very restrictive setting (i.e., a secure forensic unit). While participants were told the test results would be used only for research purposes, it seems likely that many believed that a good performance would be viewed positively by their treatment team. Finally, the issue of motivation may have been compounded by the fact that Hurley and Deal administered a battery of four malingering tests, which took as long as 2 hr to administer, while the present study involved only the administration of the TOMM. The results of this study provide data which support the use of the TOMM to assess malingering in both mildly retarded defendants and defendants who may be feigning impaired intellectual functioning; however, due to the discrepancy between the present results and those obtained by Hurley and Deal (2006), further research in this area is clearly indicated. Specifically, research assessing the utility of the TOMM with mentally retarded defendants, who still have active charges, is needed.

Discussion

The utility of the Test of Memory Malingering (TOMM) with mentally retarded forensic patients was assessed. Twenty-one adjudicated forensic inpatients, who had been diagnosed with mental retardation, were administered the TOMM. The majority of these patients also suffered from an Axis I mental disorder. The participants attained a mean score of 48.7 on Trial 2, with only 1 participant scoring below the standard cutoff for malingering (i.e., 45). The participants attained a mean score of 49.4 on the Retention Trial, with no participants falling below the cutoff for malingering. The results clearly indicate that mildly retarded forensic patients can perform well on the TOMM. The findings provide evidence that the TOMM can be used in the assessment of mildly retarded criminal defendants with little fear of obtaining false indications of malingering. 2007 Wiley Periodicals, Inc. J Clin Psychol 63: 339344, 2007. Keywords: forensic patients; malingering; mental retardation; Test of Memory Malingering

Mia B. Malaluan HR1B