Mental Competency

The first three waves of research on resilience in development, largely behavioral in focus, contributed a compelling set of concepts and methods, a surprisingly consistent body of findings, provocative issues and controversies, and clues to promising areas for the next wave of resilience research linking biology and neuroscience to behavioral adaptation in development. Behavioral investigators honed the definitions and assessments of risk, adversity, competence, developmental tasks, protective factors, and other key aspects of resilience, as they sought to understand how some children overcome adversity to do well in life. Their findings implicate fundamental adaptive systems, which in turn suggest hot spots for the rising fourth wave of integrative research on resilience in children, focused on processes studied at multiple levels of analysis and across species.

Although the vast majority of individuals with intellectual disabilities (ID) are lawabiding citizens, there is a small percentage with offending behaviour that is considered antisocial, socially inappropriate, or defined as illegal. It has long been recognised that individuals with ID or mental-health needs who break the law should be dealt with differently from the general population. There have been an increasing number of empirical studies in this area; however, these have been plagued by various definitional and methodological issues. Prevalence estimates of offenders with ID are complicated by diagnostic variations and inconsistencies in the criminal justice process. International studies have shown a large range, from 2% to 40%, depending on methodological approaches. The following review will highlight the salient issues including prevalence of offending, characteristics of offenders, vulnerabilities within the legal system, assessment, and a brief overview of intervention and treatment approaches.

Background: Consensus recommends early recognition of memory problems through multi-disciplinary assessment in memory clinics; however, little is known about the experiences of people accessing such services. The aim of this review was to synthesis empirical evidence on patient and carer experiences in the transition to dementia.

Research concerning the etiology and prevention of substance misuse has led to the development of preventive interventions that are theory-based and effective. One such approach, Life Skills Training (LST), targets key etiologic factors using a conceptual framework derived from social learning theory and problem behavior theory. LST has been extensively tested in a series of randomized trials and found effective in preventing the use/misuse of alcohol, tobacco, marijuana, and other psychoactive drugs. Research demonstrates that it is effective when implemented under different delivery conditions, by different program providers, with different age groups, and with different populations. Follow-up studies provide evidence of the long-term effectiveness of LST. Independent economic analysis indicates that LST produces cost savings of as much as $38 for every dollar invested. Finally, LST offers the potential of reducing other health risk behaviors and fostering academic success.

This monograph is designed to provide surgeons with a broad overview of the common ethical problems that they are likely to encounter in their daily practice. It also demonstrates a method for approaching these problems. Finally, it presents cases that illustrate some of these problems and provides guidance to finding rational solutions.

Clinicians who treat patients with schizophrenia may encounter a variety of ethical issues related to both psychiatric and medical treatment of patients. While informed consent is a crucial aspect of the care of all patients, it may present special challenges for patients with schizophrenia. Schizophrenia is a severe mental illness that is frequently accompanied by neuropsychological deficits. These impairments, as well as psychotic symptoms and lack of insight, can affect patients' abilities to make fully informed decisions about their own care. Ensuring that consent for treatment is informed, voluntary, and competent can thus become a more difficult endeavor. The ethical principles underlying treatment of these patients, however, are the same as those guiding treatment of all patients. Informed consent, as an embodiment of these ethical principles, represents the expression of individual rights in both clinical and research contexts. Attention to the process of informed consen...

Offenders with serious personality disorders challenge forensic systems throughout the world. In this article, the authors describe the legal system that shapes the forensic treatment of personality-disordered offenders in the Dutch psychiatric and correctional systems. The evolution of laws and regulations are addressed, as is the bifurcation of treatment between forensic hospitals and correctional settings. Prevalence data of personality disorders in the Dutch systems are presented, and comparisons between the Dutch and American systems are delineated. Current treatment modalities are described. Research initiatives and future directions for the system are presented.

Background
Mental capacity is central to legal and ethical debates on the use of compulsion in psychiatry.

Aims
To describe the clinical epidemiology of mental incapacity in patients with psychiatric disorders, including interrater reliability of assessments, frequency in the psychiatric population and associations of mental incapacity.

Method
Cross-sectional studies of capacity to consent to treatment for psychiatric patients were systematically reviewed from Medline, EMBASE and PsycInfo databases. Information on the reliability of assessments, frequency and associations of mental incapacity was extracted.

Results
Out of 37 papers reviewed, 29 different capacity assessment tools were identified. Studies were highly heterogeneous in their measurement and definitions of capacity. Interrater reliabilities between tools were high. Studies indicate incapacity is common (median 29%) but the majority of psychiatric in-patients are capable of making treatment decisions. Psychosis, severity of symptoms, involuntary admission and treatment refusal were the strongest risk factors for incapacity.

Conclusions
Mental capacity can be reliably assessed. The majority of psychiatric in-patients have capacity, and socio-demographic variables do not have a major impact but clinical ones do.

There has been increasing recognition of the high physical morbidity in patients with severe mental illness, but little has been written about cancer in these patients. Therefore, we review the published work on risk of cancer in patients with severe mental illness, treatment challenges, and ethical issues. Severe mental illness is associated with behaviours that predispose an individual to an increased risk of some cancers, including lung and breast cancer, although lower rates of other cancers are reported in this population. Severe mental illness is also associated with disparities in screening for cancer and with higher case-fatality rates. This higher rate is partly due to the specifi c challenges of treating these patients, including medical comorbidity, drug interactions, lack of capacity, and diffi culties in coping with the treatment regimen as a result of psychiatric symptoms. To ensure that patients with severe mental illness receive eff ective treatment, inequalities in care need to be addressed by all health-care professionals involved, including those from mental health services and the surgical and oncology teams.

The present study is the first to examine patterns in sibling relationship quality and the associations of these patterns with internalizing and externalizing problem behavior, as well as self-perceived competence, in middle childhood. Self-report questionnaires (e.g., Sibling Relationship Questionnaire, Self-Perception Profile for Children, Youth Self Report) were administered among 1,670 Dutch children (M age ϭ 11.40 years, SD ϭ .83) attending 51 different Dutch schools. Three sibling relationship clusters were found: a conflictual cluster (low on warmth, high on conflict), an affect-intense cluster (above average on warmth and conflict), and a harmonious cluster (high on warmth, low on conflict). Sister pairs were underrepresented in the conflictual cluster and overrepresented in the harmonious cluster. Children with conflictual sibling relationships reported significantly more internalizing and externalizing problems, and lower academic and social competence and global self-worth, than children with harmonious sibling relationships. Children with affect-intense sibling relationships reported less aggression and better social competence than children with conflictual sibling relationships. Our findings indicate that it is fruitful to combine indices of sibling warmth and conflict to examine sibling relationship types. Relationship types differed significantly concerning internalizing and externalizing problems, but also concerning self-perceived competence. These findings extend our knowledge about sibling relationship types and their impact on different aspects of child adjustment. Whereas harmonious sibling relationships are the most beneficial for adjustment, sibling conflict mainly has a negative effect on adjustment in combination with lack of sibling warmth. Implications and future directions are discussed.

| A large proportion of human social neuroscience research has focused on the issue of decisionmaking. Impaired decision-making is a symptomatic feature of a number of neurodegenerative diseases, but the nature of these decision-making deficits depends on the particular disease. Thus, examining the qualitative differences in decision-making impairments associated with different neurodegenerative diseases could provide valuable information regarding the underlying neural basis of decision-making. Nevertheless, few comparative reports of decision-making across patient groups exist. In this Review, we examine the neuroanatomical substrates of decision-making in relation to the neuropathological changes that occur in Alzheimer disease, frontotemporal dementia, Parkinson disease and Huntington disease. We then examine the main findings from studies of decision-making in these neurodegenerative diseases. Finally, we suggest a number of recommendations that future studies could adopt to aid our understanding of decision-making cognition.

This article analyzes judicial determinations on the "right to die" from Quinlan to Cruzan, Glucksberg, and Vacco. The body of law known as right-to-die cases extends ordinary treatment refusal doctrine to end-of-life decisions. The courts, having affirmed a right to refuse life-sustaining treatment, held that certain categorical distinctions that had been drawn lacked a rational basis. No rational distinction could be made between competent vs incompetent patients, withholding vs withdrawing treatment, and ordinary vs extraordinary treatment. The courts, however, had persistently affirmed one categorical distinction: between withdrawing life-sustaining treament on the one hand and active euthanasia or physician-assisted dying on the other. In Washington v Glucksberg and Vacco v Quill, the Supreme Court unanimously held that physician-assisted suicide is not a fundamental liberty interest protected by the Constitution. Notably, five members of the Court wrote or joined in concurring opinions that took a more liberal view. The Court powerfully approved aggressive palliation of pain. The Supreme Court, hinting that it would find state legalization of physician-assisted suicide constitutional, invited the nation to pursue an earnest debate on physician assistance in the dying process.

Background Aggressive challenging behaviour is frequently reported in adults with intellectual disability and it is often treated with antipsychotic drugs. However, no adequate evidence base for this practice exists. We compared fl exible doses of haloperidol (a typical, fi rst-generation antipsychotic drug), risperidone (an atypical, second-generation antipsychotic), and placebo, in the treatment of this behaviour.

Reading disabilities such as dyslexia, a specific learning disability that affects an individual's ability to process written language, are estimated to affect 15-20% of the general population. Consequently, elementary school teachers encounter students who struggle with inaccurate or slow reading, poor spelling, poor writing, and other language processing difficulties. However, recent evidence may suggest that teacher preparation programs are not providing preservice teachers with information about basic language constructs and other components related to scientifically based reading instruction. As a consequence preservice teachers have not exhibited explicit knowledge of such concepts in previous studies. Few studies have sought to assess preservice teachers' knowledge about dyslexia in conjunction with knowledge of basic language concepts. The purpose of the present study was to examine elementary school preservice teachers' knowledge of basic language constructs and their perceptions and knowledge about dyslexia. Findings from the present study suggest that preservice teachers, on average, are able to display implicit skills related to certain basic language constructs (i.e., syllable counting), but fail to demonstrate explicit knowledge of others (i.e., phonics principles). Also, preservice teachers seem to hold the common misconception that dyslexia is a visual perception deficit rather than a problem with phonological processing. Implications for future research as well as teacher preparation are discussed.

Objective To assess the effects of Alzheimer's disease (AD) and Mild Cognitive Impairment (MCI) on simulated car driving ability. Methods Twenty patients with a probable AD of mild severity (Clinical Dementia Rating, CDR ¼ 1) were compared with 20 subjects with MCI (CD ¼ 0.5), and a group of age-matched neurologically normal controls on a driving simulation task. Measures of driving competence included the length of run, the number of infractions (omission of stop at pedestrian crossings, speed limits violation), the number of stops at traffic lights, the mean time to collision, and the number of off-road events. Results in the driving competence measures were correlated with scores obtained from simple visual reaction times and mini-mental state examination (MMSE). Results The patients with mild AD performed significantly worse than MCI subjects and controls on three simulated driving measures, length of run and mean time to collision ( p < 0.001), and number of off-road events ( p < 0.01). MCI subjects had only a significantly shorter time-to-collision than healthy controls ( p < 0.001). Simple visual reaction times were significantly longer ( p < 0.001) in patients with AD, compared to MCI and healthy controls, and showed a borderline significant relation ( p ¼ 0.05) with simulated driving scores. Driving performance in the three groups did not significantly correlate with MMSE score as measure of overall cognitive function.

Evaluating parents in the context of possible abuse or neglect involves unique challenges. This paper describes a practice model for conducting clinical evaluations of parents' ability to care for young children (under age 8). Core features of the model include (a) a focus on parenting qualities and the parent–child relationship, (b) a functional approach emphasizing behaviors and skills in everyday performance, and (c) application of a minimal parenting standard. Several factors complicate the assessment task, namely, the absence of universally accepted standards of minimal parenting adequacy, the coercive context of the assessment, the scarcity of appropriate measures, difficulties predicting future behavior, and the likely use of the evaluation in legal proceedings. In the proposed model, the evaluator (a) clarifies specific referral questions in advance; (b) uses a multimethod, multisource, multisession approach; (c) organizes findings in terms of parent–child fit; (d) prepares an objective, behaviorally descriptive report that articulates the logic for the evaluator's clinical opinions regarding the referral questions; and (e) refrains from offering opinions regarding ultimate legal issues. The paper describes requisite skills needed to conduct parental fitness evaluations, sample methods, and a protocol for writing the evaluation report.

Intentionality, or Theory of Mind, is the ability to explain and predict the behaviour of others by attributing to them intentions and mental states and is hypothesised to be one of several social cognitive mechanisms which have impacted upon brain size evolution. Though the brain activity associated with processing this type of information has been studied extensively, the neuroanatomical correlates of these abilities, e.g. whether subjects who perform better have greater volume of associated brain regions, remain to be investigated. Because social abilities of this type appear to have evolved relatively recently, and because the prefrontal cortex (PFC) was the last brain region to develop both phylogenetically and ontogenetically, we hypothesised a relationship between PFC volume and intentional competence. To test this, we estimated the volume of four regional prefrontal subfields in each cerebral hemisphere, in 40 healthy adult humans by applying stereological methods on T1-weighted magnetic resonance images. Our results reveal a significant linear relationship between intentionality score and volume of orbital PFC (p = 0.01). Since this region is known to be involved in the processing of social information our findings support the hypothesis that brain size evolution is, at least in part, the result of social cognitive mechanisms supporting social cohesion.

It is often claimed that the autonomy of heroin addicts is compromised when they are choosing between taking their drug of addiction and abstaining. This is the basis of claims that they are incompetent to give consent to be prescribed heroin. We reject these claims on a number of empirical and theoretical grounds. First we argue that addicts are likely to be sober, and thus capable of rational thought, when approaching researchers to participate in research. We reject behavioural evidence purported to establish that addicts lack autonomy. We present an argument that extrinsic forces must be irresistible in order to make a choice non-autonomous. We argue that heroin does not present such an irresistible force. We make a case that drug-oriented desires are strong regular appetitive desires, which do not compromise consent. Finally we argue that an addict's apparent desire to engage in a harmful act cannot be construed as evidence of irrational or compulsive thought. On these arguments, a sober heroin addict must be considered competent, autonomous and capable of giving consent. More generally, any argument against legalisation of drugs or supporting infringement of the liberty of those desiring to take drugs of addiction must be based on considerations of harm and paternalism, and not on false claims that addicts lack freedom of the will.

As the number of cognitively impaired elderly persons increases, the need for evidencebased assessments of their capacity to consent to medical treatment and research participation will grow. The authors conducted an electronic and manual literature search for all English-language articles examining the decision-making capacity of elderly persons with dementia or cognitive impairment, reviewing articles in relation to key areas of methodological, clinical, and policy importance. The 32 relevant studies identified were highly heterogeneous, even in their definitions and measurements of decisional capacity. Although incapacity is common, many persons with dementia are capable of making their own medical and research decisions. In Alzheimer disease, memory and executive-function deficits predict decisional impairment. Still, at least in early stages of dementia, interventions may improve decisional abilities. Short and simple cognitive screening may be useful by identifying persons in need of more intensive evaluations. The use of expert judgment-based methods may mitigate the problem of a lack of a criterion standard for competence. Research into the decisionmaking competence of cognitively impaired elderly persons is a growing field. It is beginning to yield findings with practical implications for preserving the autonomy and welfare of this group of vulnerable elderly patients. (Am J E lderly patients with cognitive impairment and the clinicians who care for them face a challenge. These patients are at significant risk for having impaired decisional abilities. In this population with high medical comorbidity, the patients will face important diagnostic and treatment decisions-decisions about where to live, and decisions related to planning for future inca-pacity. At the extreme are end-of-life treatment decisions, such as assisted suicide. For example, a key issue in the controversy over a physician-induced death of a 71-year-old Dutch man with dementia was his competence to request euthanasia. 1 Oregon's Death with Dignity Act legalizes physician-assisted suicide and, when indicated, specifies a role for mental health profession-

Aims and objectives. To provide a narrative synthesis of research findings on instruments or tools designed to aid assessment of patient capacity to consent to treatment. Background. Capacity assessment is of significant priority within health care as a finding of incapacity is a vehicle for the removal of many of an individual's fundamental rights. Despite there being many instruments and tools available to aid health professionals in the assessment of patient capacity, there are no standardised guidelines from professional bodies that inform the assessment of mental capacity. Design. Integrative review.

Little is known about the prevalence of violence and autistic spectrum disorders. This article reviews findings of current research on Asperger's disorder and violence. Criteria for diagnosing Asperger's disorder are given. Three cases are presented in which defendants with diagnosed Asperger's disorder were charged with murder. Specific symptoms in this disorder are discussed as they relate to issues of diminished capacity and criminal responsibility.

Child witnesses must undergo a competence examination in which they must show appropriate conceptual understanding of lying and truth-telling, and promise to tell the truth. Three experiments (Ns = 123, 103, 177) were conducted to address the assumptions underlying the court competence examination that (1) children who understand lying and its moral implications are less likely to lie and (2) discussing the conceptual issues concerning lying and having children promising to tell the truth promotes truth-telling. Both measures of lying and understanding of truth-and lie-telling were obtained from children between 3 and 7 years of age. Most children demonstrated appropriate conceptual knowledge of lying and truth-telling and the obligation to tell the truth, but many of the same children lied to conceal their own transgression. Promising to tell the truth significantly reduced lying. Implications for legal systems are discussed.

The legal debate about patient autonomy focuses mainly on mental capacity and provision of information. The influence of the family on the decisions of the competent adult patient has scarcely been discussed in English medical law. Dominated by the bioethical principle of individual autonomy, the law concentrates on the patient and takes an exclusionary stand regarding relatives. Hence, the aim of this article is to examine the attitude of English law towards the involvement of relatives when patients make decisions, and to investigate the views and experiences of patients and their relatives in reality. To fulfil this aim, a qualitative study was carried out in six NHS trusts in England. The study was based on in-depth interviews conducted with patients who suffer from long-term illnesses, and their relatives. In the interviews, patients stated that the relatives assisted them in making informed decisions about treatment. Patients said that relatives had an influence on the decision-making process and on the decision itself, but also reported that ultimately relatives left the final decision to the patient. The findings reflect a relational approach to patient autonomy. When making decisions about treatment, patients needed to know that their relatives would support them no matter what they decided. However, exceptional cases which demonstrated substantial familial influence suggest that the law should secure the patient&amp;#39;s interest in making their own decisions. In light of these findings, it is argued that the current exclusionary attitude expressed in English medical law towards the role of relatives should be changed.

The development of risk assessment in Sweden is presented and discussed in terms of practical problems and ethical dilemmas. A central task within Swedish forensic psychiatry has always been to identify dangerous, mentally disordered subjects prone to commit violent acts. A natural point of departure, and thus the empirical basis for these risk assessments, has generally been the psychiatric factors characterising the individual patient. These risk assessments, which have been used as guidelines for treatment and rehabilitation efforts, are primarily associated with pre-trial forensic psychiatric investigations, psychiatric compulsory treatment, and during later years also with life-timers applying for a fixed-term penalty. Although risk assessments are mainly focused on psychiatric patients, regulated by law and thus strongly linked to the legal system, and often used as grounds for coercive measures and integrity violations, no broad political debate has been seen. Even more alarming is a lack of clear and concise instructions and guidelines from the authorities in charge combined with the judicial system's pronounced expectations to have firm predictions delivered by the professionals within the field.

There has been increasing recognition of the high physical morbidity in patients with severe mental illness, but little has been written about cancer in these patients. Therefore, we review the published work on risk of cancer in patients with severe mental illness, treatment challenges, and ethical issues. Severe mental illness is associated with behaviours that predispose an individual to an increased risk of some cancers, including lung and breast cancer, although lower rates of other cancers are reported in this population. Severe mental illness is also associated with disparities in screening for cancer and with higher case-fatality rates. This higher rate is partly due to the specifi c challenges of treating these patients, including medical comorbidity, drug interactions, lack of capacity, and diffi culties in coping with the treatment regimen as a result of psychiatric symptoms. To ensure that patients with severe mental illness receive eff ective treatment, inequalities in care need to be addressed by all health-care professionals involved, including those from mental health services and the surgical and oncology teams.

The Test of Memory Malingering (TOMM) has not been adequately validated in a forensic psychiatric setting. Dissimulation of cognitive impairment, as assessed by the TOMM, was evaluated in a group of 25 forensic inpatients admitted for evaluation of Competency to Stand Trial (CST/MSO group), and hypothesized to be at higher risk for feigning cognitive impairment. A comparison group of 36 patients, who were either civilly committed or adjudicated Not Guilty by Reason of Insanity (CIVIL/NGRI group), were hypothesized to be less likely to feign cognitive impairment. Groups were comparable in age, education, premorbid intelligence, and psychiatric symptom severity. Significantly more CST/MSO patients (36%) scored below a recommended TOMM cutoff score relative to CIVIL/NGRI patients (6%). Findings indicate excellent specificity and modest sensitivity, and generally support the validity of the TOMM in a forensic psychiatric population. The utility of different cutoff scores and need for multiple indicators of effort are discussed.

Background Researchers have noted difficulties in attracting adequate numbers of participants with intellectual disabilities (ID) to their studies. Methods This study was a review of participation by adults with ID in research conducted in South Eastern Ontario over a 20-year period (1987)(1988)(1989)(1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006). Original research studies were identified by local investigators and then reviewed for inclusion and exclusion criteria. The report of each study was then reviewed by three reviewers and key information was extracted. The extent of study participation was calculated using three methods and compared along with key design characteristics. Results Nine studies met all inclusion/exclusion criteria and provided sufficient data to calculate participation. Among the studies there was a variety of purposes, research designs and recruitment strategies. Using the participant/approached calculation, participation varied between 41.8% and 100%. Higher participation was observed in studies where investigators had direct access to participants, the data collection was non-invasive and consent was required from substitute decision-makers only. There was no clear trend of increasing or decreasing participation over time.

Although end-of-life care is a relatively common option for patients with terminal cancer, it has become available only recently for patients with Alzheimer&amp;#39;s disease. Alzheimer&amp;#39;s disease is a chronic process of gradual deterioration of cognitive ability and the resulting deficits in activities of daily living. The chronic disease course of Alzheimer&amp;#39;s disease gives to the clinician the opportunity to look ahead and plan for the final stages of care. This article presents a review of palliative care interventions for patients with Alzheimer&amp;#39;s disease and other dementias. End-of-life care for individuals with end-stage Alzheimer&amp;#39;s disease is increasingly important because of the increasing number of patients with this disease. However, there are barriers to providing high-quality end-of-life care. Currently, palliative care is not optimal for Alzheimer&amp;#39;s patients. Health care systems and clinicians should make efforts to improve the suffering of patients with this disease and their caregivers.

This study compared the legal abilities of defendants (N = 212) with current primary psychotic disorders (n = 44), affective disorders (n = 42), substance abuse disorders (n = 54), and no diagnosed major mental illness (n = 72). Defendants with primary psychotic disorders demonstrated more impairment than did other defendants in their understanding of interrogation rights, the nature and object of the proceedings, the possible consequences of proceedings, and their ability to communicate with counsel. Psychosis was of limited value as a predictor however, and high rates of legal impairment were found even in defendants with no diagnosed major mental illness. Sources of within-group variance were examined to further explain this finding. Policy and clinical implications of these results are discussed.

The assumption that mental disorder is a cause of crime is the foundation of forensic psychiatry, but conceptual, epistemological, and empirical analyses show that neither mental nor crime, or the causation implied, are clear-cut concepts. "Mental" denotes heterogeneous aspects of a person such as inner experiences, cognitive abilities, and behaviour patterns described in a non-physical vocabulary. In psychology and psychiatry, mental describes law-bound, caused aspects of human functioning that are predictable and generalizable. Problems defined as mental disorders are end-points of dimensional inter-individual differences rather than natural categories. Deficits in cognitive faculties, such as attention, verbal understanding, impulse control, and reality assessment, may be susceptibility factors that relate to behaviours (such as crimes) by increasing the probability (risk) for a negative behaviour or constitute causes in the sense of INUS conditions (Insufficient but Non-redundant parts of Unnecessary but Sufficient conditions). Attributing causes to complex behaviours such as crimes is not an unbiased process, and mental disorders will attract disproportionate attention when it comes to explanations of behaviours that we wish to distance ourselves from. Only by rigorous interpretation of what psychiatry actually can inform us about, using empirical analyses of quantified aggressive antisocial behaviours and their possible explanatory factors, can we gain a clearer notion of the relationship between mental disorder and crime.

The aim of this article is to explore some of the ethical issues surrounding the assessment and determination of capacity of people with dementia in light of their meaning-making ability as shown through discourse. Discourse analysis, two illustrative cases, social construction theory and positioning are used to highlight some of the ethical dilemmas involved in basing a determination of capacity on the diagnosis of dementia and neuropsychological tests of cognitive function. Although neuropsychological tests have their place in assessing some aspects of cognitive function, aspects cognition such as meaning-making ability and selfhood cannot be assessed in a standard format. In dementia, there can be a differential impairment of recall memory while the personality, values and substantial long-term memory remain intact, as does implicit memory for recent events. People with dementia are vulnerable to being negatively positioned, thereby unfairly undermining their rights to make decisions about aspects of their lives. Assessing the capacity of a person with dementia to engage in decision-making is presently in need of examination so as to take into account the person's meaning-making ability and selfhood. Incorrect negative positioning, based on the diagnosis and defects in recall memory, can obscure intact cognitive abilities that allow a person to make decisions about aspects of living, creating the possibility of lasting harm being inflicted on the person with dementia.

The association between scores on MMPI-2 scales and cognitive symptom validity test (SVT) failure was investigated in 127 criminal defendants evaluated for competency to stand trial, criminal responsibility, and drug dependence, and 141 personal injury and disability claimants. Results indicated that SVT failure was associated with exaggerated symptom presentation involving somatic complaints in civil litigants and more global exaggeration of psychopathology and somatic complaints in criminal defendants. Scores on the MMPI-2 Fake Bad Scale (FBS) were associated with SVT failure in both civil and criminal litigants, whereas scores on the MMPI-2 F P scale were associated with SVT failure in criminal defendants, but not in civil plaintiffs. These results support the utility of the FBS as an indicator of non-credible presentation of somatic and cognitive complaints in both civil and criminal forensic psychological assessments, and indicate that the lack of association between the MMPI-2 infrequency scales and SVT failure is limited to civil forensic settings.