Barbara is a 76-year-old woman whose husband passed away two years ago. She lives alone, but sees her boyfriend, Bob, nearly every day. Barbara’s daughter, Jenny, scheduled a dementia evaluation due to concerns about Barbara’s lapses in financial and household management. Jenny noted that the physician had ruled out any medical explanations for these difficulties after completing extensive lab work, a physical exam, and a review of current medications. Given information obtained during the initial interview and observations that could be consistent with lifelong inattention and executive dysfunction, the clinician considered ADHD as part of the differential diagnosis and added the CAARS 2 to Barbara’s evaluation battery. This is Barbara’s first psychological evaluation; she has no prior mental health history.

This case study illustrates the following:

• Assessing for ADHD in an older adult
  
  
• Using a gender-matched normative sample
  
  
• Interpreting CAARS 2 Observer data in the absence of Self-Report ratings
  
  
• Resolving discrepancy between DSM Impulsivity T-score and Symptom Count
  
  
• Examining discrepancies between observers

Barbara and Jenny arrived 10 minutes late for the appointment. Barbara appeared flustered, but well-groomed and dressed appropriately for the setting. She was pleasant but made it clear that she was “not going senile.” She seemed cheerful and was quick to engage the clinician in small talk about a family picture on his desk and current controversies in the local schools. Jenny interrupted to say that she and her brother had noticed their mother struggling with everyday tasks since their father, Johnny, passed away two years ago. Jenny added that she became more concerned when she learned Barbara was overspending, to the point that she took out a loan. Those concerns led to the discovery that Barbara often had late fees, accrued interest on utility and credit card bills, and late tax payments. Barbara replied that Johnny had wanted her to have nice things and told her she would be comfortable after he died. She was able to describe her recent purchases, without any apparent memory problems. Jenny said that Barbara had always been and continued to be good with remembering names, faces, and dates, though she had never been good at things like remembering to get prescriptions filled. She was also notorious for running late because she got side-tracked, “just like today.”

As the interview continued, the clinician learned that Barbara met her late husband in high school. She left college to marry him after he got his first job. Barbara explained that she always enjoyed learning, but often forgot about due dates, tests, and assignments. She added, “Who has time to keep track of nitpicky details when there are more interesting things to do!” She said she loved being married, that she took care of the children and Johnny took care of the money. Currently, she finds that bills and other important mail often get misplaced around the house. She said, “I woke up yesterday and resolved to find the bills first thing after breakfast, but then I saw a bird and filled the birdfeeder, and noticed some weeds coming up around the birdbath, and looked for my hand trowel, but found some zinnia seeds I forgot to plant this Spring, and before I know it, it’s already lunchtime and I’m too hungry to sit down at my desk. That’s just how it goes.”

Throughout the interview, Barbara often brought up anecdotes that were tangential and lengthy, albeit charming. She was easily distracted by environmental noises like a phone ringing in the waiting room and a dumpster pick-up in the parking lot. It was rare for her to answer a question directly. During testing, Barbara frequently had errors in her spelling and math. When asked about whether she had difficulty with those areas as a child, she said, “My teachers always said I needed to be more careful and check my work.” Barbara was good at conversational turn-taking and did not interrupt. She did not appear restless. She did not show impulsivity during the evaluation.

Results from a cognitive evaluation showed age-appropriate reasoning and memory skills. Barbara had an erratic performance on the Conners Continuous Performance Test 3rd Edition™ (Conners CPT 3™; Conners 2014; a task-oriented assessment of attention-related problems including the areas of inattentiveness, impulsivity, sustained attention, and vigilance), with results suggesting inattention and vigilance problems (relative to what is typical of individuals of the same age and gender). She said she was too tired to complete the CAARS 2 in the clinic but agreed to do it at home. She requested a paper copy. Barbara signed a release of information so links to the online Observer form could be sent to Jenny and Bob. Despite several follow-up calls and emails, Barbara did not complete the self-report form. Results from the Observer forms are provided in Table 5.3.

The clinician chose the age- and gender-matched sample when scoring the CAARS 2. Following the CAARS 2 Interpretation Guidelines (see chapter 4, Interpretation), he recorded the following notes about Bob and Jenny’s ratings for his personal reference:

1. Response Style Analysis. All Response Style metrics are in the acceptable range.
   
   
2. Associated Clinical Concern Items. Jenny said her mother “occasionally” feels sad, which warrants follow-up because Barbara is in the 70+ age group. No reported suicidal ideation, self-harm, or anxious feelings.
   
   
3. CAARS 2 Scales. The overall CAARS 2 profile was mostly in the average range; Bob’s ratings had peaks around inattention, and Jenny’s ratings had peaks around inattention and impulsivity. On the Content Scale T-scores, the Inattention/Executive Dysfunction T-score was elevated for both Bob and Jenny. The Impulsivity T-score was elevated for Jenny, but not Bob. Both observers had elevations for DSM ADHD Inattentive Symptoms, but only Jenny had an elevation for DSM Hyperactive/Impulsive Symptoms and the DSM Total ADHD Symptoms. The DSM Inattentive Symptom Count was 6/9 for Bob and 7/9 for Jenny, but the DSM Hyperactive/Impulsive Symptom Count was below 5/9 for both observers. Both raters’ CAARS 2–ADHD Index scores were elevated, indicating that ratings of Barbara were more similar to individuals in the clinical ADHD sample than to individuals her age in the General Population Sample.
   
   
4. Item-level responses. Inattention items show a similar pattern for both Bob and Jenny on Content and DSM Symptom Scales alike; Bob rated a couple of these items just a little lower than Jenny. They endorsed the same items on the impulsivity scales too, but with a wider discrepancy between their ratings. Bob tended to say “occasionally” whereas Jenny said “often.”
   
   The clinician returned to the discrepancy between Jenny’s DSM Hyperactive/Impulsive Symptoms T-score (T = 63, Slightly Elevated) and her corresponding Symptom Count (4/9, below DSM Criterion A threshold). He reviewed the CAARS 2 Single-Rater Report, paying close attention to the Items by Scale table for the DSM Hyperactive/Impulsive Symptoms scale. He observed that Jenny described that her mother “very often” has trouble doing leisure activities quietly and intrudes on others’ activities. She rated low levels of other features of impulsivity. The clinician cross-referenced items on the Impulsivity Content Scale, and noted Jenny endorsed other examples of impulsivity that are not included in the DSM items, such as seeking immediate gratification, acting and speaking before thinking, rushing through things, and being impatient.
   
   A few Impairment & Functional Outcome Items were elevated for both raters, including managing money, household responsibilities, and time online. Both observers indicated that problems described on the CAARS 2 “very often” interfered with Barbara’s life. They both endorsed that Barbara “sometimes” had problems in her relationships with significant others and family members. Jenny’s responses to the Additional Questions described her mother’s quick wit and steel-trap memory as strengths, and financial management and decision-making as concerns. Bob said he was worried about Barbara keeping up with bills, but that otherwise she was a lot of fun.
   
   
5. Integration of CAARS 2 data. Big picture, Jenny and Bob both see features of inattention. Jenny describes more impulsivity than Bob. The elevated ADHD Index probability scores indicated that observer ratings of Barbara were more similar to individuals with ADHD than to individuals in the General Population Sample. Validity scales were in the acceptable range, and the CAARS 2 observer data were all consistent with interview data and behavioral observations.

Having completed his review of the CAARS 2 results, the clinician examined discrepancies between the two observer descriptions of impulsivity. Given that Bob generally sees Barbara in social contexts whereas Jenny is more aware of her finances, the clinician decided that both reports were likely accurate but described Barbara in different settings. The clinician considered his interview notes and observations and decided that while Barbara shows slightly more impulsivity than most women her age (particularly with respect to her finances), she did not meet DSM-5-TR criteria for the hyperactive/impulsive presentation. Both Bob and Jenny endorsed high levels of inattention (Content Scales, DSM Symptom Scales T-scores, and DSM Symptom Counts). Those features were prominent in Barbara’s self-described history, and there was evidence of inattention in the testing observations. The clinician summarized, “Barbara shows more features of inattention than expected for a woman her age, across settings. She has elements of impulsivity, particularly financial impulsivity, but she does not show strong evidence for other forms of impulsivity or hyperactivity.” On the basis of the interview with Barbara, observations of her behavior during the evaluation, results from the assessment of her attention, and observer ratings on the CAARS 2, the clinician assigned a DSM diagnosis of ADHD, Predominantly inattentive presentation, noting that Barbara met full symptomatic, age-of-onset, pervasiveness, and impairment criteria (DSM Criteria A, B, C, and D), and that he had ruled out other possible explanations such as anxiety, depression, and dementia (Criterion E). He noted additional features of impulsivity that were most evident in financial decisions.

When Barbara and her daughter returned to review the results, the clinician asked once more if Barbara had brought the completed self-report form with her. She apologized profusely, saying, “I just don’t know what I did with it.” He moved on and asked about Jenny’s rating of “occasional” sadness. Barbara said, “At my age, you have some sad times, but they pass quickly.” Jenny agreed, saying that her mom seemed happy most of the time. The clinician followed up about the ratings of time spent online, and Jenny smiled, saying her mother had more friends on social media than she did, but that she didn’t think it was really a problem. Barbara agreed, saying that she uses social media to stay in touch with her friends.

The clinician shared his impressions, including that Barbara did not currently show signs of dementia or mild cognitive impairment. He explained how her lifelong pattern of inattention fit with a diagnosis of ADHD, and offered the hypothesis that things seemed worse of late because Barbara now had to manage her own finances without ever having been taught skills such as budgeting or tracking expenses. Barbara triumphantly declared, “I told you I wasn’t senile!” Jenny looked relieved and added, “I probably should have told you that both of my kids have ADHD, but it didn’t occur to me that Mom could have it.” The clinician discussed strategies that may be helpful to Barbara, including working with a financial manager for budgeting, spending, and bill-paying. The possibility of a medication trial was suggested, and Barbara agreed she would consider it if things didn’t get better on their own.