Evaluating Continuous Performance Tests as Embedded Measures of Performance Validity in ADHD assessments: A Systematic Review and Meta-Analysis

Continuous Performance Tests (CPTs) are widely used in neuropsychological evaluations for adult ADHD to assess cognition, yet their potential role as embedded performance validity indicators remains unclear. Given the need for efficient and empirically supported tools to detect non-credible performance, especially in ADHD assessment where concerns regarding performance validity are prevalent (occurrence of non-credible performance and/ or symptom reporting are ranging from 9 to 16%), this work offers clinically relevant insights. The use of CPTs allows for the simultaneous assessment of performance validity and core cognitive constructs such as attention and response inhibition, making them a time-efficient tool in clinical practice In this study, we conducted a systematic review and multilevel meta-analysis (including 18 studies, 3021 participants and 67 effect sizes) to synthesize findings across both simulation and criterion-group designs, evaluating the extent to which CPTs can differentiate between credible and non-credible test performance in ADHD assessments. We also examined the role of two potential moderating factors, including study design (criterion‑group vs. simulation group) and sample characteristics (student vs. non-student). We hypothesized that CPTs would demonstrate moderate effectiveness in identifying non‑credible performance, with larger effects in simulation group design in comparison to criterion group design. We expected the effect larger in non-student samples in comparison to student samples. Furthermore, we conducted two additional exploratory analyses, including variants of the CPT and specific outcome measures (omission errors, commission errors, reaction time, and reaction time standard deviation) Our findings indicate that CPTs demonstrate moderate utility in distinguishing non-credible from credible performance. Simulation designs generally yielded stronger effects than criterion group designs, highlighting the critical role of study design in interpreting research outcomes. No signifcant differences were found between student and non-student groups. These findings suggest that CPTs may be useful as embedded validity indicators in adult ADHD assessments, though they should be used in conjunction with other validity measures.