Maria, a bright, 50-year-old, married woman, sought this evaluation after her 12-year-old daughter was diagnosed with ADHD Combined presentation. Maria, who has a history of peripartum depression but has never been evaluated for ADHD, said it felt like déjà vu when the evaluator summarized her daughter’s strengths and challenges, and she wondered if she might also have ADHD. She described herself as “a full-time mother who works on a very part-time basis.”

This case study illustrates the following:

• First-time assessment of an adult with suspected ADHD
  
  
• Detecting ADHD when symptoms are masked by strong compensatory strategies that come at a cost
  
  
• Integrating discrepant self-report and observer ratings
  
  
• Use of CAARS 2 to monitor response to treatment
  
  
• Integrating full-length and short-form results

Maria arrived 15 minutes early for her initial appointment. She provided a tabbed three-ring binder of her childhood and college report cards, as well as results from a 7th-grade evaluation that qualified her to participate in a prestigious university’s Talent Identification Project and adult IQ testing that she used to join MENSA. She appeared somewhat uncomfortable initially but quickly warmed up and engaged readily in conversation. The clinician noticed a pattern where Maria would briefly mention a difficulty, then quickly minimize it with remarks describing it as “no big deal” or “not really a problem.” For example, she said, “Sometimes I get overwhelmed by so many emails … but really I can handle it when I put my mind to it and stay on track with my print-and-file system.”

Maria described being keenly aware of the many sacrifices her parents made (e.g., working multiple jobs, leaving family and friends behind) to enable them to immigrate from Mexico to the United States shortly before her birth. As the eldest of three daughters in her family, her adherence to the Latinx cultural value of familismo has driven her to meet her parents’ high expectations for academic performance and career success. Maria also expressed her appreciation for “Tia Marta,” a middle school teacher who became “like a guardian angel and aunt.” She explained that Marta took an interest in her, given the similarities in their backgrounds, and mentored her in a variety of ways (e.g., applying for summer camp scholarships, preparing for SATs, writing college application essays, and practice interviewing for jobs). Maria did well in school, although she didn’t have much time for a social life because she often used the weekend to catch up on schoolwork and get ahead on projects. She was recruited as a human resources consultant after college and was in high demand due to her success with difficult clients and being bilingual. She often felt like she had to work harder and longer than her colleagues.

Maria met her partner, Amy (a nurse practitioner), when they were both 28 years old. They had a commitment ceremony two years later and married as soon as same-sex marriage became legal in their state. When asked about her current relationship with Amy, Maria enthusiastically described their wedding day and shared photos of their daughters. When the clinician gently pointed out the disparity between her response and the question asked, Maria laughingly said, “Yes, that’s true. Amy says I’m all over the place! To answer your question, she balances me. I wear my heart on my sleeve, and she stays even-keeled.” Maria became tearful describing how hard things were when Amy was trying to get pregnant with an anonymous sperm donor. After a few years of “heartbreak and frustration,” they decided to change strategies and Amy took a full-time position while Maria tried to get pregnant. They were thrilled when they learned they were expecting. Amy had been promoted to an administrative position in the healthcare system with a great salary and whole-family benefits, so once Carmen was born, Maria transferred most of her consulting clients and became primarily a stay-at-home mom. They now have 3 daughters: Carmen (age 15), Jamie (age 13), and Morgan (age 12).

The clinician asked about Maria’s reported history of peripartum depression. She explained that she was very eager to be a mother, so it was a shock when she found herself unable to enjoy anything after Carmen was born. At first, she thought it was just fatigue from being up all night with a crying baby, but then it didn’t go away. Amy convinced Maria to go see a counselor because she didn’t seem like her usual enthusiastic self. Things improved after Maria began following a plan that included daily exercise, intentional adult time, increased contact with her parents and sisters, weekly psychotherapy, and joining a new mother’s group. Maria said she knew what to expect with her subsequent pregnancies, so she and Amy got her supports in place beforehand which “helped a lot.” When asked about other instances of depression, Maria said she had days when she felt “blue,” but nothing like how she felt for a few months following childbirth.

The clinician asked Maria how motherhood compared with consulting. Maria said it was “shocking,” adding that she had always been able to hyperfocus at work by wearing noise-canceling headphones and shutting her office door. She described her work schedule before children as, “… a rollercoaster, I would enjoy time with friends and family, then frantically work dawn to dusk to meet a deadline, then take a few days to recover before the next deadline popped up.” In contrast, she described motherhood as, “… one big, messy, job with nested layers of complexity, where you are never, ever done and nobody can clarify expectations for success.” She said she thought she would be well-suited because “… pulling all-nighters was no problem … in hindsight, three children in four years might have been a bit much, but at the time I just loved those babies and wanted more.” Maria quickly added, “But I figured it out and everything is great. Being a mother of three is not a big deal. I love it, especially special times like Carmen’s quinceañera this year which meant the world to my parents; it was unforgettable. I probably let some things slide while I was focused on that, but it was worth it.”

When asked about daily household management, Maria said she is really good at delegating. They have a housekeeper who comes three days a week to clean, do laundry, get groceries, prepare meals, and help with schoolwork. The children also meet with tutors twice a week. Maria half-jokingly said, “If I could hire a consultant for myself, I’d be set!” She thought she could return to part-time work once her youngest child entered middle school, but she found Morgan needed more help than her sisters. Morgan was diagnosed with ADHD last year, and Maria said, “It was like looking into a mirror as the doctor explained all of the ways Morgan was working so hard to make up for her challenges. He could have been describing me as a child.” The clinician asked Maria to elaborate, and she launched into a non-stop stream of details, “… that child never stops talking, she is always asking something or telling something, she can’t listen but has to jump into every conversation, she asks questions but then doesn’t wait to hear what you say, she is just a little Energizer bunny who goes and goes all day until suddenly boom, she’s sound asleep on the couch. She can’t stand school and all that ‘be quiet, sit down’ stuff, which I totally get because long meetings make me crazy. She can never find her stuff and we’re always late because of the explosion of stuff that happens in her room and really the whole house every minute of her life. The tutor has been a life-saver because she actually gets her homework done those days, but even then I have to be 100% dedicated to her and ignore everything else in the house or else nothing would get done. I still don’t know what happened to that permission slip for her field trip last week, the teacher says she never got it but I can’t find it at home so it must be at school somewhere. Or in her backpack, maybe we should clean out her backpack. But wait, what was it you asked me?” The clinician refocused Maria, asking if she had the same experiences in childhood. She replied, “Well, yes and no. I think in a different family I might have, but messiness, disrespect, and tardiness were not acceptable when I was growing up, so I figured it out. Maybe I’ve been too easy on Morgan.” Further discussion revealed that Maria had developed many strategies over the years, such as setting up a system that worked and following it every time. She said that sometimes people think she’s “rigid,” but really, it’s because, “I know if I deviate from the system even a little bit, I’ll forget something.” She looked serious for a minute, saying, “Sometimes I wonder what my clients would think if they knew how chaotic my life really is … I look like I’ve got my act together when I’m with them but behind the scenes, it’s a different story.” She quickly smiled and said, “But isn’t that true for any mother of three who tries to work?! Really, things are fine overall, I am just curious about whether this could be genetic since that could be helpful for Morgan to know.”

The clinician decided that a careful history, interview, observations, and rating scales would be sufficient for this evaluation of suspected ADHD, given that Maria did not need formal documentation for school or work and there was no suggestion of a possible learning disorder or intellectual disability that might warrant standardized testing. Maria, who opted for English-language versions of the assessment forms, completed the CAARS 2 from her smartphone while in the clinic waiting room. The clinician emailed Amy a link to the online Observer form after obtaining a release of information from Maria.

Results from the initial full-length CAARS 2 forms are presented in Table 5.1.

The clinician was very familiar with the CAARS 2, so he quickly reviewed the Interpretation Guidelines (see appendix D) as he interpreted Maria’s baseline data, including self-report and observer ratings. (Note: The wording for the following content is informal because it reflects the clinician’s personal interpretation notes verbatim.)

1. Response Style Analysis. Response Style looks fine overall for self-report. Amy did the Observer form; those validity scales are clean as well; typical pace, no omits, no concerns about her Response Style.
   
   
2. Associated Clinical Concern Items. Nothing flagged for self or observer report.
   
   
3. CAARS 2 Scales. Maria’s profile is completely flat for normative comparisons with the General Population Sample. Spouse has several elevations (relative to the normative sample), her report is closer to what I observed and to examples Maria gave in interview. Maria’s Content and DSM Symptom Scales scores look pretty clean, but Amy’s ratings describe high activity levels, emotional dysregulation, negative self-concept; some impulsivity shows up on the DSM scale (both T-score and Symptom Count). Not a lot of inattention on either rating, I’ll need to check into that because in interview it sounded like she is compensating for a lot of inattention and executive dysfunction on a daily basis. Could be that Maria manages attention problems but at a cost. Wonder if impression management is a factor with some of Maria’s ratings, because what she described to me doesn’t match up with how she rated herself. She was quick to take back any self-criticisms. ADHD Index is low on the Observer report, very low on the Self-Report.
   
   
4. Item-level responses. Okay, let’s check the Items by Scale to see what’s happening with these DSM items. Why isn’t the Symptom Count higher for inattention? (pause) OK, looking at observer’s DSM items … I see, she hits several of the DSM Inattention items at a 1, none of them cross over threshold to get counted. And Maria’s self-report … hmm … she clears threshold for “talks a lot,” that’s for sure right, and has a sprinkling of 1s (“Just a little true; Occasionally”) on losing things, finishing tasks, staying focused, blurting, interrupting, feeling restless … I can see why she didn’t hit the Symptom Count but she has a lot of these DSM items endorsed even with her saying things are “fine” overall. And she marked 0 (“Not true at all; Never/Rarely”) for most things, so it looks like even a rating of 1 means something for Maria. Looking at the Content Scales, same pattern … Maria rarely rates above a 1, but her 1s match up with the 2s (“Pretty much true; Often/Quite a bit”) and 3s (“Completely true; Very often/Always”) on the Observer report. On the Impairment & Functional Outcome Items Maria says she feels like an underachiever. She describes occasional driving risks. Her wife’s ratings produced a number of elevated scores; Amy’s report is closer to what I observed and to examples Maria gave in interview. Amy says risk-taking with driving, also notes mild problems in family relationships and sleep. Quick glance at the Additional Questions … Maria says very little on the weaknesses item, noting that motherhood can be challenging; spouse describes that Maria often seems overwhelmed and can lose her temper at times, but always has good intentions and is just as quick to apologize. For strengths, Maria focuses on academic and past professional success, achievement-focused strengths. Spouse describes many character strengths, sees the whole person.
   
   
5. Integration of CAARS 2 data. Overall, the spouse’s ratings are closer to what I observed and to what Maria described during the interview. Check with Maria at feedback meeting about her level of awareness/insight. Is she engaging in impression management or just unaware of how often things are happening? Or maybe she’s compensating and not recognizing the cost of that. Everything other than the CAARS 2 Self-Report suggests ADHD, at least Hyperactivity and Impulsivity; interview suggests there are also INA/EDF features that are not captured in the ratings. Need to check in about how persistent these symptoms are, I have retrospective report of onset in childhood, and it sounds like this has been an issue at home given Amy’s report. Need a better idea about whether there was a hidden cost at school, what did it take to get those straight A report cards? Sounds like definite challenges and costly compensation at work, she was working almost double-time to be successful. I don’t see anything to suggest other diagnoses on the table; no substance use; no hints of personality disorder, depression, or anxiety; no evidence of LD or ID. Final question is whether this is full ADHD, if so which presentation, or it may be a situation where I go with Other Specified. Will get additional info at results meeting.

Maria and Amy arranged their schedules so they could both attend the results meeting. The clinician shared that, overall, there were several signs that Maria was dealing with symptoms of ADHD, including the struggles she described during the interview, her wife’s ratings, and the clinician’s observations. He said it was very impressive that Maria consistently accomplishes so much, and that she must be working very hard to do so. Maria teared up, and Amy reached over to comfort her. Maria apologized, saying, “I’m sorry, I’m usually good at keeping it together, but it’s just such a huge relief to hear you say that. I have spent most of my life working all the time to make up for not getting everything done as easily as other people.” The clinician followed up and learned that Maria constantly felt like she was “faking it and not actually smart enough to do the job.” She described, “I learned to act like everything was always okay, because that’s how it had to be when I was growing up. Mama said, ‘Just show them what you want them to see,’ and I did.” The clinician asked if she maybe was thinking about that when completing the rating scale; Maria said, “I didn’t mean to do it, but maybe I was. I didn’t want you to think badly of me. I mean, I know it’s your job, but still … .” Amy picked up the conversation and added, “Maria is such a strong and capable woman, it took a long time for her to feel safe being vulnerable with me. She feels very deeply, but she’s really good at putting on her ‘everything’s great’ mask.” Maria nodded in agreement. The clinician followed up about the level of insight and awareness and discovered that Maria is fairly aware but feels very guilty about “failing as a mom.” She said, “Without the housekeeper, tutor, and Amy, nothing would ever get done.” The clinician followed up on specific items to better understand why Maria’s CAARS 2 Self-Report inattention scores were lower than expected, given all other sources of information. Maria explained that when she is working, she triple-checks important work to catch her many mistakes, and that she takes notes in important meetings to help her pay attention. She described an intricate day-planner system she used prior to her smartphone, saying when she worked full-time her personal assistant at work, Judy, had to remind her of personal items like family trips and school concerts. When the clinician asked Maria about her ratings on these items on the CAARS 2, she said, “Well, it’s really not an issue for me right now. But if I went back to work full-time, I’d 100% need Judy again to avoid having problems in those areas.”

Given this information, the clinician reviewed DSM criteria for ADHD and decided that Maria showed a persistent pattern of pervasive hyperactivity/restlessness and impulsivity (more emotional/verbal than motoric) that emerged in childhood and interfered with her functioning. These concerns were pervasive, not limited to episodes of depression. She had evidence of inattentive features in her background, but she and her wife did not rate these at high levels on the rating scale—likely because she has benefitted from many compensatory supports and strategies; without these, she would probably show more elevations on the inattentive items. Although Maria earned good grades and was well-regarded at work, this came at a cost to her personal and social life. Her work life had been optimized by supports, like a full-time personal assistant, which made her challenges less apparent. The clinician assigned a DSM diagnosis of Other Specified ADHD, noting that Maria’s presentation is consistent with Combined presentation but that with her current level of support, she did not meet the full symptom count for the Inattentive aspect of the diagnosis. The clinician explained that Maria’s hyperactivity and impulsivity took the form of restlessness, high energy levels, verbal impulsivity, and some emotional impulsivity. After reviewing the diagnosis, the clinician talked with Maria about her success with setting up consistent organization systems for school and work, and she agreed that she would like to meet with an executive coach to develop and implement systems that will help her be more effective with managing the household. They discussed how having children can take away the buffers of time, space, and energy that helped her compensate in the past, and considered ways to access those resources so she can enjoy more of her time with the family rather than feeling overwhelmed or guilty. They talked about the ways she and Amy complement each other, and that it could be helpful for Maria to learn some self-soothing skills she can use even when Amy is at work, formalizing some of the intuitive cognitive strategies she developed on her own, particularly given her vulnerability to stress and history of peripartum depression. Finally, they discussed that Maria might be a good candidate for a medication trial and the clinician provided a referral to area psychiatrists who had experience with adult ADHD. They planned to meet again in a year to evaluate progress made, or sooner if things were not improving in three months.

A few months later, Maria called to say she had gained practical strategies and coping skills in therapy, but she was still struggling. She wanted to consider medications, but couldn’t find where she wrote the psychiatrists’ names. The clinician gave Maria that information again and offered to speak with her chosen psychiatrist, if that would be helpful. After Maria told the clinician that she had made an appointment with one of his referrals, he obtained a release and called that psychiatrist to discuss coordinating care, including medication monitoring. After obtaining a signed release of information from Maria, they made plans to coordinate services. The clinician emailed links to the CAARS 2–Short to Maria and Amy for them to complete before Maria tried the new medication, and another set of links to be completed after a month of the new medication. (He suggested waiting one month so there would be time for the psychiatrist to confirm medication and dosage before ratings were completed.) Maria and Amy completed the CAARS 2–Short right away (see “Midpoint” in Table 5.2).

The clinician compared results from baseline and current (“midpoint”) ratings, following the steps outlined in appendix D of the CAARS 2 manual. His informal notes are provided below:

• Norms Selection: Keep default; Combined Gender as the principal reference group.
  
  
• Response Style: No concerns for self or spouse response style.
  
  
• Associated Clinical Concern items do not appear on short form.
  
  
• Scales: Self-Report profile has some peaks and valleys now, different from the first time we met. Maria is definitely not an over-reporter though. I still need to pay attention to any slight elevation as that’s saying a lot for her. Why did Maria’s Content T-scores go up when she says things are getting better? I wonder if her symptoms have actually increased? Or maybe she feels more comfortable disclosing her struggles now, compared to her under-reporting the first time we worked together? She’s had more practice with self-disclosing in therapy. I’ll check with her when we meet. I probably should have asked her to do the short form before she started therapy, given how much denial she had the first time she did the CAARS 2. Spouse has a similar shape to the initial profile; trend toward improvement in regulating emotions, but not statistically significant yet. Where are the DSM scores? … Oh that’s right, they’re not included on the short form.
  
  
• Item-level: Short form does not include impairment items. Maria is more forthcoming on the weaknesses item now, and says she is often very self-critical and that she finds she can be short-tempered at home. Spouse reports things are getting better with temper management on the weaknesses item. Maria is able to describe some personal strengths now, says she is improving her coping strategies. Spouse continues to describe many positive qualities, including that Maria is getting better about taking feedback without blowing up.
  
  
• Integrate: Although first glance at the self-report data might suggest things are getting worse for Maria since some of her T-scores went up, closer reflection in context reveals that things are getting better, her work in therapy is helping her open up and admit vulnerabilities. Spouse ratings suggest some movement in the right direction for emotional self-control. Check in with them about these hypotheses. The hyperactivity and restlessness are still in the picture, unusual for a woman, but it fits with her daughter’s presentation. It will be interesting to see if this changes with medication trial.

The clinician spoke with Maria by phone to give her brief feedback on the midpoint ratings. Maria agreed with his interpretation. She shared that she had negative side effects from the first medication, so they agreed that she would wait until a month-long trial of a successful medication before she and Amy completed their next set of ratings.

A couple of months later, the clinician received a new set of data from Maria and Amy (see “Final” in Table 5.2). The clinician compared these with the baseline and midpoint reports for Maria and Amy and dictated his impressions:

• Response Style: No concerns for self or spouse.
  
  
• Scales: Looking across Maria’s evals, baseline was under-reported. Midpoint and final ratings both have similar shape, but notably lower peaks at the final assessment, especially for activity levels and impulsivity. For spouse, activity levels looking better. Self-concept is moving in the right direction, will take time to balance those negative internal scripts. Overall, this combination of therapy and medication seems to be working.
  
  
• Item-level: Maria’s current responses to the Additional Questions show a shift from her baseline, from downplaying areas of weakness to owning them. Spouse noted that Maria seems more confident and less reactive since starting treatment. She wrote that Maria seems less restless, but that it could be they are both better at knowing her limits and planning shorter conversations rather than marathons, or it could be meds.
  
  
• Integrate: Looking at self-report versus observer report for the final ratings in comparison with baseline and mid-point, the scores are more closely aligned now; in fact, most of them are not significantly different. Big change from baseline, where spouse reported more concerns than Maria did. Maria is more able to express what’s happening in her life. Comparison of the three points in time shows significant spikes from baseline (when she was trying to present herself in a positive light) to midpoint (when her ratings more closely matched other sources of information), and now decreased scores since she has been in psychotherapy and taking medication. Spouse form shows steady progression of improvement in talk therapy, then adding medication helped with activity level, restlessness, verbal impulsivity, and some social intrusion; baseline to final is clinically meaningful change. Looks like current treatment plan is working.

Maria and Amy returned to review the treatment monitoring results. They agreed with the clinician’s summary of notable improvement in functioning and decrease in symptoms with the current combination of cognitive-behavioral therapy, environmental changes, and medication. They discussed that Maria still has ADHD, but it is well-managed and therefore less impairing. They reviewed her plans to continue maintenance meetings with her therapist to make sure things stay on track. Maria commented, “I hadn’t even realized how stressed I was about everything until things started to get better. I feel so much better now, like I can get through the day without losing it in the first hour.” Amy joined in, “Yes, Maria has always been a great partner but I feel like she’s there for me more often now, she’s less strung-out and exhausted when I get home from work. We can enjoy being together again.” The clinician asked about the medication, and Amy said, “I can definitely tell if she forgets to take it.” Maria said, “Yes, we have figured out a system so that doesn’t happen again, except for when we went on vacation and there was a little snafu there. But we have a new plan.” The clinician helped them anticipate major life events that may be challenging, such as when their daughters begin college or if their parents become ill, and reminded them of resources that will be helpful as those needs arise. With Maria’s permission (and a signed release form on file), the clinician sent a summary letter to the treating psychiatrist and therapist. He indicated that he was glad to consult as needed if Maria experiences a change in her functioning or tries a different medication.