Evaluating the independent and combined accuracy of Rey Auditory Verbal Learning Test (RAVLT) Effort Score and Forced Choice embedded performance validity tests

BACKGROUND: Embedded performance validity tests (PVTs) provide an efficient means of assessing validity in neuropsychological evaluations. Multiple embedded PVTs have been developed for the Rey Auditory Verbal Learning Test (RAVLT), most notably the Effort Score (ES) and Forced Choice (FC) recognition paradigms. However, there is limited research examining whether ES and FC provide nonredundant information, particularly across levels of cognitive impairment. This study examined the independent and combined accuracy of the RAVLT ES and FC embedded PVTs for detecting invalid neuropsychologist test performance. METHODS: Data came from 487 mixed neuropsychiatric outpatients evaluated at an academic medical center who completed the RAVLT and four independent criterion PVTs. Study validity groups were defined invalid based on failure of two or more criterion PVTs (22%). Valid participants were further classified as no impairment, mild, or major neurocognitive disorder. RESULTS: Significant performance differences were observed across all RAVLT scores with large effects. ES and FC were moderately correlated overall, with weaker correlations in the no impairment group. FC was a consistent predictor across all impairment groups, whereas ES showed reduced predictive utility among the mild impairment group. Combined models demonstrated improved classification accuracy compared to either indicator alone. CONCLUSION: RAVLT ES and FC represent distinct but complementary embedded PVTs. FC is more robust in genuine cognitive impairment and should be prioritized in impaired populations, whereas ES provides incremental value in cognitively intact individuals. These findings support the use of multiple embedded RAVLT PVTs in clinical practice.