The use of the Test of Memory Malingering (TOMM) with Hispanic-Americans Lorna Myers, Ph.D. Director of Clinical Neuropsychology Northeast Regional Epilepsy Group

If they don’t speak English, just test them visually “visuo-spatial and non-verbal tests allow us to bypass language barriers” Not so fast: Anastasi, 1988; Irvine and Berry, 1988, Harris, Tulsky & Schultheis, 2003, Harris, Wagner & Cullum, 2007, Roselli & Ardila, 2003.

If they don’t speak English, just test them visually Ponton, Satz et al. showed in 1996 that US based Spanish speakers’ scores were different to mainstream norms even on tests that were visual-motor in nature (e.g. ROCFT).

If they don’t speak English, just test them visually Saez (2011) assessed Spanish-speaking and English-speaking Hispanics and non-Hispanic white epilepsy patients on non-verbal tests. Education, ethnicity and English-language fluency affected completion time on the grooved pegboard test. English speaking Hispanic patients obtained a significantly higher score than their Spanish- speaking counterparts on a test of visual memory.

If they don’t speak English, just test them visually Von Thomsen, Gallup et al. (2008) reported that Performance subtests actually had a lower predictive validity in schooling.

The TOMM The Test of Memory Malingering (TOMM, Tombaugh T, 1996) was designed to discriminate between malingered and true memory impairments. Standardization: 70 cognitively intact individuals recruited from the community (17-73 years, mean education 12.7 years). No mention of ethnicity, race or language preference is made in the manual.

The TOMM The mean scores for this sample were: Trial 1: 47.8 Trial 2: 49.9 The percent of cognitively intact adults who correctly identified 45 or more items on Trial 1 was 90% and was at 100% at a score of 47 or higher on Trial 2. According to the manual, suggested interpretation of the test is that 1) scoring lower than chance on any trial indicates the possibility of malingering and 2) a score lower than 45 on Trial 2 indicates the possibility of malingering.

The TOMM and Spanish speaking patients 44 patients consecutive patients with confirmed diagnoses of: dementia (mild to severe---n=16) epilepsy (n=24) Parkinson’s (n=2) hydrocephalus (n=1) stroke (n=1) were administered the complete battery. 3 patients were excluded because the reason for referral was traumatic brain injury and potential litigation was unclear. One patient was excluded because she was actively involved in litigation

Our sample 29 females, 15 males Mean age: 56 years (SD=16.8) Mean education: 10.2 years (SD 4.16). No patients were involved in litigation nor had any apparent secondary gain that would lead to purposeful exaggeration of cognitive impairment.

Results Mean score of 41.8 (SD=8.14) on Trial 1. 50% (22/44) of the Spanish speaking group scored less than 45 on Trial 1 21% (9/44) of our sample “failed” Trial 2 in that they scored below 45/50. 2 of those nine earned a “less than chance score” on Trial 1 or 2 (<25). Of the patients who “failed” the second trial of the TOMM, 5 were diagnosed with epilepsy, 1 had mild dementia, 2 had moderate to severe dementia and 1 had hydrocephalus. Patients with a confirmed diagnosis of epilepsy were among the two who earned a ‘less than chance score” on both trials.

What does this mean? According to the TOMM manual interpretation guidelines, 2 of our epileptic subjects would have fulfilled both criteria suggesting “possibility of malingering.” In addition, 9 out of our 44 patients would fulfill criteria 2 from the manual. The possibility of malingering carries much weight in the courts. Suggested cutoffs with Spanish speaking clients should be adapted in order to improve sensitivity and specificity of this measure.

Future Directions… Standardization studies of the TOMM that include (racially, ethnically, linguistically) representative samples. Analysis of the 50 line drawings to assure cultural universality Attorneys and neuropsychologists who encounter TOMM results cited in reports of Spanish speaking clients in which a suggestion of malingering is being made should challenge this.