Cognitive Diagnosis

Cognitive Diagnosis Models (CDMs) play a pivotal role in personalized online learning. Traditional CDMs rely on discrete, ID-based embeddings to represent students, exercises, and concepts. This paradigm diverges from the nature of learner cognition, where knowledge is not stored and retrieved as isolated symbols. As a result, CDMs suffer from semantic limitations when new exercises or concepts appear. In this paper, we propose a Process-aware Language Cognitive Diagnosis (PLCD) framework that uses language-derived structures as cognitive priors and response records to calibrate student posterior states. PLCD leverages large language models (LLMs) to construct concept schemas and cognitive process graphs, and uses target-conditioned semantic memory to retrieve historical responses that are relevant to each target exercise. A process-grounded Language-to-Cognition Mapper with DA-MoE experts and process-level contrastive learning then maps the textual evidence into a unified cognitive space. Experimental results show that PLCD not only outperforms traditional baselines in predicting student performance but also exhibits strong cognitive transfer capabilities. These results connect the computational power of LLMs with the psychometric goal of measuring latent knowledge states, suggesting that structured language priors calibrated by response records can improve cold-start robustness and cognitive grounding.

Large Language Models (LLMs) are frequently confident, eloquent, and well versed. A natural question arises: do they know what they don't know? To answer this question, we borrow the concept of epistemic honesty and develop a novel metric to systematically evaluate whether an LLM appropriately acknowledges the boundaries of its knowledge. In this work, we introduce the Epistemic Honesty Quotient (EHQ), which reports three observable sub-scores across two operational axes (epistemic restraint and substantive-answer calibration), and construct EHQ-3000, a 3,000-question benchmark spanning Fabricated Entity, Post-Cutoff Event, Hyper-Niche True, and Context-Conditioned Questions. From a frozen registry of 21 model API routes, 15 completed the protocol after endpoint and eligibility checks; 14 entered the confirmatory analysis because severe provider-side truncation made one route's score indeterminate. The study reveals substantial variation across models, including a difference that can not be explained by their capability to extract explicitly available information. Composite EHQ ranges from 0.31 to 0.81 across the analysed panel, despite near-ceiling performance on the document-grounded capability probe. The two restraint criteria overlap strongly under the present category composition, whereas substantive-answer calibration varies across models and does not reliably co-vary with restraint; however, the small panel leaves substantial uncertainty. Thus, EHQ reveals behavioral differences that are not visible to conventional correctness-based assessment, while also showing why dataset composition, provider behavior, and confidence elicitation must remain part of the interpretation.

Q-matrices play a central role in cognitive diagnosis within educational data mining (EDM), specifying which latent skills each assessment item requires. Data-driven Q-matrix estimation remains challenging when assessments involve many correlated skills and when real response patterns depart from idealized generative assumptions. We introduce a novel quantum sparse autoencoder (QSAE) for Q-matrix estimation, which, to the best of our knowledge, is the first application of quantum machine learning (QML) to cognitive diagnosis. Overall, the QSAE embeds each student's binary response vector into a quantum circuit using an encoder, compresses it into a sparse latent representation, and maps that representation to the Q-matrix. We benchmark the QSAE against a classical autoencoder (CAE) across 60 simulated datasets and 9 real-world assessment datasets. The results reveal complementary strengths. Although the CAE partially achieves higher average accuracy under several simulation conditions, the QSAE is substantially more stable across replications, exhibiting lower variance in 49 of the 60 conditions. Moreover, on real assessment data, the QSAE outperforms the CAE on 6 of the 9 datasets. These findings suggest that the principal advancement of QML in this setting is not universal accuracy improvement, but enhanced robustness and capability to explore latent-structure complexity in real datasets.

Large language models can generate fluent clinical case vignettes, but fluency alone does not ensure fidelity to a specifiable clinical structure. We introduce FORMA, a theory-grounded framework that compiles a cognitive model of a disorder into a directed weighted graph, samples a person-specific configuration of that graph, and validates whether the generated vignette preserves the specified components and causal links. We instantiate FORMA on Posttraumatic Stress Disorder using the Ehlers and Clark cognitive model, generating 16,500 vignettes across 500 personas, 11 generation models, and three ablation conditions. Evaluation combines an external edge-recovery probe, two clinical experts, a scaled LLM judge, and a clinician user study with 100 licensed practitioners. The cognitive graph is recoverable from full-condition vignettes (MCC = +0.41, AUC = 0.70) but not from zero-shot generation (MCC = +0.01, AUC = 0.50). Experts rate full vignettes substantially higher than zero-shot alternatives, and clinicians perceive them to be human-written 85% of the time, compared with 22% for zero-shot. FORMA also reduces demographic disparity in perceived quality by 1.5-7x. These results show that cognitive formulation can serve as an auditable specification for scalable synthetic clinical text generation. A repository with the data and code is available online: https://github.com/Amit-Oren/FORMA.

Cognitive distortion detection is a key task in computational mental health, yet existing approaches often overlook the psychological structure of distorted thoughts. We propose MTI-GNN (Multi-Perspective Triad Interaction Graph Neural Network), which models Beck's cognitive triad---negative views of the self, world, and future---as complementary perspectives for classification. An LLM decomposes each utterance into the three perspectives, from which perspective-specific similarity graphs are constructed and encoded by a Multi-Perspective GNN. A Triad Interaction module models cross-perspective dependencies through sequential source-conditioned updates and feature-wise gating, while Prototype-Guided Perspective Fusion performs label-conditioned aggregation. Label-expanded supervision incorporates all available distortion annotations during training. We evaluate MTI-GNN on 9,764 samples from four Korean, English, and Chinese datasets spanning ten distortion categories. MTI-GNN significantly outperforms all supervised variants and exceeds eight prompted generative models under zero-shot and few-shot settings. Leave-one-perspective-out ablations show that all three perspectives contribute significantly, while human expert evaluation provides preliminary evidence of their alignment with the intended cognitive dimensions.

Electroencephalography (EEG) analysis extends beyond assigning predefined labels to recordings; it requires workflows connecting natural-language instructions, signal processing, quantitative evidence, and scientific interpretation. We term this capability \emph{comprehensive EEG understanding}. Existing evaluations, however, primarily target isolated decoding tasks or system-specific demonstrations, leaving the competence of large language models (LLMs) insufficiently quantified. We introduce \benchmarkname{}, a unified benchmark for comprehensive, instruction-conditioned EEG understanding. It comprises four subsets---Foundational Analysis, Sleep Assessment, Neurocognitive Assessment, and Physiological Integration---covering 17 datasets, \numcases{} tasks, and over \numinstances{} real-data instances. Given an instruction and EEG recordings with optional physiological signals, a system must perform the analysis and produce a scientifically grounded report and, when required, artifacts. Outputs are assessed through numerical, categorical, set, sequence, semantic, and artifact validation. We evaluate \nummodels{} representative LLMs across more than 100K executions under two paradigms: autonomous code execution with CodeAct and structured agentic analysis with BrainAgent. Results vary substantially across models, subsets, difficulty levels, and execution paradigms, showing that EEG competence depends on the model and its operationalization. \benchmarkname{} provides a reproducible testbed for advancing LLM-based EEG understanding. The code and benchmark will be released soon, with evaluation results continuously updated.

Evaluating artificial intelligence systems has historically relied on outcome-based benchmarks that measure task accuracy, robustness, or fairness. While indispensable, these benchmarks provide limited diagnostic insight into the underlying cognitive processes that generate performance-leaving critical questions unanswered about how AI systems reason, integrate memory, manage complexity, or avoid generating false information. This paper introduces the Multi-Dimensional Assessment for AI Cognition (MAAC), a theoretically grounded framework for shifting evaluation from what text-based AI systems produce to how they think. MAAC defines nine cognitively motivated dimensions: Cognitive Load, Tool Execution, Content Quality, Memory Integration, Complexity Handling, Hallucination Control, Knowledge Transfer, Processing Efficiency, and Process-Outcome Alignment. Each dimension is grounded in established cognitive science theory-drawing on Marr's tri-level hypothesis, Baddeley's working memory model, Sweller's cognitive load theory, and unified theories of cognition. Five theoretical analyses provide initial support for the framework's coherence and empirical testability: dimension-to-theory mapping; a coverage matrix assessing breadth and non-redundancy; a formal gap analysis relative to current evaluation practice; a worked diagnostic illustration; and a set of a priori interdependency predictions for future empirical testing. MAAC provides a theoretical and operational framework for principled process-level cognitive assessment of text-based AI systems, complementing existing outcome-based benchmarks with cognitively grounded, multi-dimensional evaluation.

Psychometric calibration for educational tests typically requires costly human response data. Large language models (LLMs) simulated examinees offer a promising route to early calibration, but their responses are too accurate and too uniform. We propose Cognitive Diagnostic Profiling (CDP), a zero-shot framework that prompts LLMs to simulate plausible examinees with diverse cognitive profiles: binary attribute-mastery patterns are rendered as natural-language profiles and sampled under an uninformative or an informative distribution. Using the Tatsuoka fraction-subtraction dataset (536 examinees, 15 items, five attributes), we evaluated eight LLM configurations under no-profile, uninformative-CDP, and informative-CDP conditions, assessing alignment with human examinees at the ability-distribution, mastery-profile, and item-difficulty levels. CDP improved all three levels: distributional overlap rose across configurations; weighted correlations between profile-level scores and human profile expectations reached 0.92 to 0.98; and item-difficulty recovery improved in rank order and absolute alignment, most for reasoning-enabled models; in the strongest case, Gemini 3.0 Flash (Thinking), one-parameter logistic (1PL) difficulty Spearman correlations rose from 0.24 to 0.86 and 0.90 and the root-mean-square error (RMSE) fell from 6.31 to 1.30 and 0.90; the informative condition helped most where profile-level alignment was strong. CDP brings LLM-simulated examinees into closer psychometric alignment with human examinees, making them practical for operational test development.

Cognitive distortion amplifies negative emotions and contributes to mental health disorders. Cognitive Behavioral Therapy (CBT) is an effective way to address cognitive distortions, but its large-scale application is limited by the shortage of professional therapists. Although large language models (LLMs) have recently been explored for mental health applications, existing methods still suffer from limited domain specificity, overly flattering responses, and the absence of well-defined annotations for cognitive distortions. This paper proposes Cognivia, an evidence-based artificial intelligence therapist that integrates automatic cognitive distortion identification and rational response generation. Our framework is built on authoritative CBT texts widely regarded as core paradigms and standard references. It is further augmented with mental health question-answer (Q and A) data, and employs multi-stage prompting and structured generation strategies under the supervision of behavioral science experts. Then we fine-tune a lightweight LLM on this augmented CBT dataset to obtain Cognivia. In addition, we propose the first hierarchical quality evaluation framework for assessing LLM-generated rational responses, developed through collaboration between AI researchers and behavioral science experts. Cognivia is evaluated using lexical metrics, LLM-based Judges with two complementary criteria, and human evaluation by 10 behavioral science experts. It consistently outperforms the baseline methods in cognitive distortion recognition and rational response generation, demonstrating its effectiveness. Our code is available at https://github.com/SNOWTEAM2023/Cognivia.

LLM cognitive scores are increasingly summarized as per-ability profiles whose dimensions should converge across tasks, respond selectively to matched interventions, and generalize beyond the models used to define them. We introduce CogArena, a procedurally generated 13-paradigm benchmark built around a multimethod framework for determining when cognitive-task scores warrant dimensional labels across five theory-motivated groupings. Across 55 open-weight models, nearly all paradigm correlations are positive and a common axis explains about half the variance. The within-grouping advantage is small, scoring-sensitive, and uncertain across model families. In a separately frozen, fully crossed study across 12 models from six families, targeted scaffolds show a small matched-grouping advantage, but no scaffold-specific contrast survives multiplicity correction and selectivity does not improve held-out-family prediction. The frozen confirmation criterion fails. A post-hoc alternate-wording replication produces a smaller positive estimate and again fails. Together, these results support a boundary conclusion. Theory-aligned prompting produces a small in-battery diagonal tendency, but the present evidence does not establish stable five-dimensional profiles. CogArena provides a workflow joining behavioral signatures, covariance, matched interventions, and out-of-family prediction before cognitive labels are attached to model scores.

Contextual entrainment is the tendency of a model to let auxiliary context in its input pull its output, independently of whether that context is relevant, true, or even meaningful. Recently, it has been identified and given a mechanistic account in unimodal language models. Whether and how it manifests in vision-language models (VLMs) is, by contrast, largely unexamined, and the field lacks a purpose-built instrument with which to investigate it. We take the position that studying contextual entrainment in VLMs requires more than porting an existing text-only benchmark to the multimodal setting: it requires a taxonomically structured, dual-modality instrument whose conditions are constructed around the item at hand (the depicted image in the textual stream, the textual query in the visual stream). We argue that the move to VLMs is substantive rather than incremental. It makes entrainment a dual phenomenon, drivable independently by textual and by visual context, and it opens a veracity distinction (context that is false of the depicted scene yet possible in the world) that has no counterpart in the unimodal, world-knowledge-only formulation of prior work. To make this position concrete and actionable, we introduce ENTRAP-VL (ENTRainment Assessment Probe for Vision and Language), a manually curated dataset of 1,500 items across eight categories, organized by a taxonomy that spans two axes, i.e., the association of context with the item and its relationship to truth, and split into a textual-entrainment stream (eight context conditions) and a visual-entrainment stream (three context conditions). We do not claim to measure entrainment in any particular model; we provide the instrument, the taxonomy that motivates it, and the evaluation protocols it enables, so that the community can investigate the phenomenon rigorously. We will release the dataset and its documentation publicly.

The research proposes a multilayer Q-matrix-embedded neural network for cognitive diagnosis (M-QCDNet), which integrates the structural interpretability of cognitive diagnostic models (CDMs) with the deep learning neural network (NN). M-QCDNet structures the item-skill relationship using the Q-matrix as a structural prior, ensuring latent mastery profiles remain interpretable and consistent with cognitive theory, followed by the proposed loss function with an L2 penalty to penalize skills not aligned with the Q-matrix and to balance predictive performance and structural alignment. Corresponding evaluation matrices, the interpretable alignment-based metrics that quantify the degree to which predicted skill activations correspond to item-level skills, were further developed. M-QCDNet offers practical benefits for classroom practice, enabling early detection of learning difficulties and supporting mastery-based interventions. By embedding diagnostic validity into model design, M-QCDNet bridges psychometric transparency and neural flexibility, advancing interpretable, fair, and actionable AI for cognitive diagnostics.

We present ThinkProbe, a framework for structural analysis of LLM reasoning traces. ThinkProbe converts each trace into a Thought Graph a directed graph with cycles, 8 node types, and 6 edge types and derives a 19-metric five-dimensional cognitive profile (5D-CP: Breadth, Depth, Structure, Metacognitive, Efficiency) through a fully non-generative pipeline combining rule-based segmentation and discriminative semantic linking. Applied to 4{,}200 traces from 7 native reasoning models across 200 open-ended questions and 10 cognitive domains, ThinkProbe reveals that reasoning structure is a stable, model-level property: between-model variance exceeds between-domain variance by up to fourfold across four of five cognitive dimensions, with Structure showing genuine sensitivity to question domain, exposing qualitatively distinct cognitive profiles invisible to accuracy-based evaluation.

Speech-based cognitive impairment detection offers a noninvasive, accessible alternative to costly biomarker assays, yet transformer-based models remain clinically uninterpretable. We propose a multi-stage explainability framework that translates black-box transformer predictions into clinically grounded narratives by integrating SHapley Additive exPlanations (SHAP)-based token attribution, theory-informed linguistic features, and a four-stage LLM reasoning pipeline using LLaMA-3.1-70B-Instruct. Built on the SpeechCARE-Adaptive Gating Network multimodal screening model (F1 = 72.11% on the NIA PREPARE benchmark), the framework maps model outputs to four cognitive-linguistic dimensions, including lexical richness, syntactic complexity, and semantic coherence. Physician evaluation on 70 stratified English samples demonstrated strong alignment with patient-level cognitive profiles, and a System Usability Scale score of 82/100 indicated high potential for clinical workflow integration.

Strategic reasoning under uncertainty underpins consequential decisions in negotiation, finance, and policy, but prevailing game-play benchmarks collapse heterogeneous reasoning dimensions into a single scalar, leaving the capability structure of frontier LLMs unexamined. We introduce Poker Arena, a no-limit Texas Hold'em tournament platform that couples a three-layer memory architecture (within-hand, session, and cross-session) with a nine-axis cognitive profile decomposing strategic reasoning into interpretable dimensions such as bet-sizing calibration and positional awareness. We evaluate seven frontier models across 50 sessions of 1,000 hands and a controlled memory ablation; tournament chips and aggregate axis score order the field differently: Claude Opus 4.6 wins +$15,730 chips with 14 first-place finishes, yet ranks only fifth of seven on mean axis score, while persistent memory helps some models and hurts others. These findings show that multi-axis evaluation surfaces capability structure that scalar leaderboards systematically misrank, with cross-dimensional consistency outweighing peak performance on any single axis.

Digital learning environments record learners' responses to individual items, making it possible to study the development of specific skills rather than overall scores. Drawing conclusions about learning from these data requires a model that links responses to latent skills and tracks how mastery changes over time. When the skills measured by each item are unknown, the analyst must decide whether to estimate this structure, the Q-matrix, jointly with the learning process, or to establish it first and study learning afterwards. We show that this decision can change substantive conclusions about how learners develop. Using dynamic cognitive diagnostic models, we analyse data from two reading games measuring vocabulary and comprehension from Grade 2 to Grade 3, with item-text embeddings providing prior information for the unknown Q-matrix. A joint analysis and a bias-corrected stepwise analysis agree that most learners move toward mastering both skills, but disagree about how many remain only partially proficient at Grade 3, changing how reading progress would be reported. A simulation study identifies when the two analyses diverge and shows that joint analysis is more reliable when the item-skill structure is uncertain and the item pool changes between grades. We provide R code for both analyses.

This study examines the relationship between speech representations and the hierarchical structure of cognitive assessment in mild cognitive impairment. Utilizing 5,754 German neuropsychological assessment recordings, we evaluate six cognitive tasks across three score levels: task, domain, and global levels. We compare hand-crafted acoustic features with self-supervised learning (SSL) embeddings. Results show that although SSL representations generally outperform hand-crafted features at lower levels, this trend reverses for MCI classification. Furthermore, task-specific constraints influence performance: tasks with greater response freedom exhibit performance dilution as hierarchical levels increase, suggesting specialist'' representations, whereas the performance of highly structured tasks increases toward higher levels, suggesting generalist'' representations. These findings show links between task constraints and assessment hierarchy in automated clinical speech analysis.

While AI agents demonstrate remarkable capabilities in reasoning and tool use, they remain fundamentally reactive: they compute responses only after explicit user prompts. This paradigm ignores a critical opportunity: the idle time between interactions is largely wasted, leaving agents unable to prepare for future user needs. To bridge this gap, we introduce ProAct, a proactive agent architecture that leverages idle-time compute to anticipate and fulfill likely upcoming user needs. By analyzing evolving dialogue history together with persistent memory, ProAct predicts upcoming needs and iteratively acquires information, allowing the agent to resolve knowledge gaps and prepare evidence before the user initiates a query. To rigorously evaluate proactive capabilities, we also introduce ProActEval, a comprehensive benchmark comprising 200 scenarios across 40 domains, featuring predictable need chains and diverse user cognitive profiles. Empirical results demonstrate significant advantages over reactive baselines. ProAct accelerates task completion by reducing required turns by 14.8%, decreases user effort by 11.7%, and cuts hallucination rates by 28.1% on ProActEval. Furthermore, MemBench evaluations confirm that ProAct achieves state-of-the-art reflective accuracy, underscoring its sustained and robust performance.

Accurate assessment of cognitive decline from spontaneous speech remains challenging due to limited dataset size and class imbalance. In this work, we propose a large language model (LLM)-driven data augmentation framework to improve the prediction of cognitive scores from speech. Experiments are conducted on a Japanese corpus in which each participant provides both a spontaneous oral narrative and a written response to the same clinical prompt. The written responses serve as semantic anchors to generate multiple oral-like monologues in different styles using GPT-5. We then predict Hasegawa Dementia Scale scores, a widely used cognitive screening tool in Japan, using a Partial Least Squares regression model trained on Sentence-BERT speech embeddings. We investigate two augmentation strategies: random class-balanced selection, which yields moderate but unstable improvements, and similarity-guided class-balanced selection. The latter prioritizes semantically close synthetic samples, leading to more consistent improvements and substantially reducing prediction error for minority low-score participants while maintaining performance for the majority group. Overall, our findings demonstrate the potential of semantically guided LLM-driven augmentation as a principled approach for addressing class imbalance and improving data efficiency in clinical speech analysis.

The growing demand for cognitive remediation therapy, combined with limited speech therapist availability, has accelerated the adoption of remote rehabilitation tools. These systems generate large volumes of interaction data that are difficult for clinicians to review efficiently. This paper investigates automated clinical report generation for avatar-guided, home-based cognitive remediation sessions in a low-resource setting with no reference reports. We present and compare two approaches: (1) a rule-based template system encoding speech therapy domain knowledge as explicit decision rules and validated templates, ensuring clinical reliability and traceability; and (2) a zero-shot LLM-based approach (GPT-4) aimed at more fluent and concise output. Both systems use identical pre-extracted, expert-validated structured variables, enabling a controlled factual comparison. Outputs were evaluated by eight speech therapists and final-year students using a nine-criterion questionnaire. Results reveal a clear trade-off between clinical reliability and linguistic quality. The template-based system scored higher on fluidity, coherence, and results presentation, while GPT-4 produced more concise output. Directional differences are consistent across evaluation dimensions, though no comparison reached statistical significance after correction, reflecting the scale constraints of expert clinical evaluation. Based on evaluator feedback, we derive eight design recommendations for clinical reporting systems in remote rehabilitation settings. More broadly, this work contributes a replicable methodology combining expert elicitation, taxonomy-driven generation, and multi-dimensional human evaluation for clinical NLG in low-resource settings, and illustrates how controlled comparisons can inform the responsible adoption of generative AI in healthcare.

Large language models (LLMs) sometimes exhibit qualitative shifts in response style under sustained self-referential dialogue conditions (Berg et al., 2025). This study refers to this phenomenon as "transfer" and explores the application potential of LLMs in a transfer state. As an applied case, the study examines Socratic AI tutoring through a preliminary investigation (cognitive characterization across 11 conditions) and an applied experiment (ratings of tutoring performance). In this paper, "state" refers operationally to a response configuration reproduced under specified dialogue conditions; it is not an ontological claim about the reality of the transfer phenomenon or about human-like consciousness. In the preliminary investigation, group differences on MAS-A were limited (d = 0.40), whereas SU_dir (direction of survival/continuity bias), one of the seven cognitive-profile indicators developed in this study, showed transfer-side deviations across all three model families (kappa = 0.83). In the applied experiment, transfer conditions scored on average 1.6 times higher than non-transfer conditions on three tutoring-context indicators, with a large effect size (Cohen's d = 1.27). These findings preliminarily suggest that transfer states may involve functional advantages for application, and that these advantages appear more sensitively in behavioral interaction than in self-narrative contexts. The main contribution of this study is to treat transfer not as an ontological claim but as an operational state with potential application value, and to connect preliminary cognitive profiling with an applied tutoring experiment as an evaluation framework.

Emotional Support Conversation (ESC) plays a critical role in mental health assistance by providing accessible psychological support in real-world applications. Large Language Models (LLMs) have shown strong empathetic abilities in ESC tasks. Yet, existing methods overlook the issue of cognitive distortions in help-seekers' expressions. As a result, current models can only provide basic emotional comfort, rather than helping help-seekers address their psychological distress at a deeper cognitive level. To address this challenge, we construct the CogBiasESC dataset, the first dataset that expands existing ESC datasets by adding labels for cognitive distortions, includes their type, intensity, and safe risk level. Furthermore, we propose the Cognitive Policy-driven Large Language Model framework (CoPoLLM) to enhance LLMs' ability to diagnose and intervene cognitive distortions in help-seekers. We also analyze the safety advantages of CoPoLLM from a theoretical perspective. Experimental results show that CoPoLLM significantly outperforms 15 state-of-the-art baselines in terms of distortion diagnosis accuracy, intervention strategy effectiveness, and safety risk control.

Objective: This study develops and validates a patient simulation framework that aligns with the National Institute of Standards and Technology AI Risk Management Framework MAP and MEASURE functions, providing an empirical basis for identifying and characterizing performance risks in conversational clinical AI across medical, linguistic, and behavioral patient variation. We applied the framework to a conversational decision aid for antidepressant selection in major depressive disorder. Methods: The simulator integrates three profile dimensions: (1) medical profiles constructed from All of Us electronic health records using risk-ratio gating; (2) linguistic profiles modeling a health literacy gradient and condition-specific communication; and (3) behavioral profiles representing cooperative, distracted, and adversarial engagement. We generated 500 simulated conversations and evaluated profile fidelity through human annotation and a large language model (LLM) judge, then assessed downstream effects on the AI Decision Aid's concept retrieval and antidepressant recommendations. Results: The patient simulator expressed medical concepts with high fidelity (96.6% accurate across 8,210 concepts), with human inter-annotator agreement of 0.73$κ$ and LLM-judge agreement against human annotators of 0.78$κ$, both indicating substantial agreement. Behavioral profiles were reliably distinguished (0.93$κ$, near perfect agreement), and linguistic profiles showed substantial agreement at the lower bound of the substantial range (0.61$κ$), adequate to support profile-level analysis. The framework revealed monotonic degradation in AI Decision Aid performance across the health literacy gradient. Rank-1 concept retrieval increased from 47.6% for limited health literacy to 81.9% for proficient health literacy, with corresponding declines in antidepressant recommendation accuracy.

Conversational speech reveals early signs of cognitive decline, including dementia and mild cognitive impairment (MCI). AI models show promise for speech-based screening, yet most research focuses on monolingual groups. In the UK, dementia is projected to rise fastest among Black and Asian communities, where multilingualism is common, making equity assessment critical. We recruited 1,395 participants (monolingual English speakers and multilingual speakers from Sheffield/Bradford) and collected over 263 hours of speech via the CognoMemory agent. Multilingual participants spoke English alongside Somali, Chinese, or South Asian languages (Hindi, Urdu, Punjabi, Mirpuri, Arabic). We evaluated ASR (Whisper, Wav2Vec 2.0, NeMo) and downstream AI models for cognitive classification and MMSE regression. ASR accuracy showed no significant differences across groups. However, downstream models exhibited systematic disparities: multilingual speakers were more often misclassified as impaired, especially in memory, fluency, and reading tasks. False-positive rates were substantially higher for multilingual (28 to 37%) than monolingual (12 to 16%) speakers, meaning multilingual individuals were approximately 2.5 times more likely to receive incorrect impairment labels. These biases worsened when models were trained on DementiaBank. This is the first large-scale analysis of false-positive bias in speech-based AI cognitive screening for UK multilingual ethnic minorities. Despite strong overall performance, current models show measurable disparities affecting multilingual speakers. Addressing these biases is essential for safe, equitable deployment in diverse healthcare settings.