David is a 19-year-old single man with no prior evaluations or diagnoses. He was referred for this evaluation because he is failing most of his university classes. He has been placed on Academic Leave and withdrawn from his classes until evaluation results are available.

This case study illustrates the following:

• Differential diagnosis between ADHD and Specific Learning Disorder (SLD)
  
  
• Integrating Self-Report and Observer reports (completed by parents)
  
  
• Interpreting possible concerns in Response Style Analysis
  
  
• Caveats for an elevated ADHD Index in the absence of other elevations or clinical evidence of ADHD (Self-Report)
  
  
• Determining whether discrepancies are statistically significant and/or clinically meaningful
  
  

David’s parents were distraught when they called to schedule this evaluation. They had mild concerns during the first semester of his freshman year but attributed them to typical struggles navigating the transition to college. But they were shocked when halfway through the Spring semester, David shared a school counselor’s advice that David might have ADHD and suggested that accommodations might be provided if he received that diagnosis. They did not realize the extent of David’s academic struggles until then.

The evaluation began with a parent interview to gather information about David’s background and early development, as well as the onset and course of current concerns. The parents explained that their older daughters have thrived in school. They said in hindsight, they “should have been more on top of things” when David went to college because he always needed more help with homework growing up. Both parents were very successful academically (his father is a physician and his mother a professor). They were unaware of anyone in the extended family with a diagnosis of ADHD or learning disorders, although David’s father noted that he himself struggled with literature and reading (but excelled with lecture, discussion, and hands-on instruction). David’s parents said that several of David’s cousins had tutors, but they didn’t know why.

The prenatal and early developmental periods were uneventful for David. His parents described that when he was young, he had great concentration for things like building with Lego bricks and listening to books, but that he always hated independent reading. They commented that in hindsight, David’s kindergarten teacher commented that he often “needed to get his wiggles out” when it was time for reading and writing. In 3^rd grade, he frequently had consequences for acting out, especially during independent reading time. David attended a small parochial school from 6^th through 12^th grade, where he was well-liked by teachers and had many friends. He continued excelling with math and science content, although he did not do well on his science papers and lab reports. Report card comments, particularly from his English/Language Arts (ELA) teachers included, “David needs to dig deeper . . . his comments in discussion show he is very bright . . . he needs to apply himself and stop taking the easy way out on papers.” David’s parents recalled that he was most likely to procrastinate for ELA, and sometimes History courses. They often ended up helping him organize and type his papers at the last minute, remembering that he had good ideas and knew the material, but just couldn’t get it together to complete papers on time. His work history included being a lifeguard in the summers. His parents proudly shared that he took the job very seriously, saying he wouldn’t even talk to them when he was working because he was attending to what was happening in the pool.

When the clinician met with David, he said that he felt awful about “bombing” college and being a disappointment to his parents, adding that he really had tried hard and spent more time studying than partying. When he got the first low grades back on papers, he resolved to try harder and began going to the library to write. He was frustrated that his science classes had essays on the exams, which were “never good for me.” David said that he just couldn’t keep his mind on all the reading and that he had always hated writing. When asked about things that were easy to pay attention to, he listed video games, math, lectures, labs, conversations, and movies. The clinician followed up on emotional health after hearing David’s negative self-talk and guilt; David described that he was generally happy and got along well with people. He said he felt sad from time to time, like when his grandfather died, but that he didn’t get “stuck on it” like his sister did. He described feeling pretty good about himself, other than the parts of school that “suck.” He said he sleeps well, has a good appetite, and enjoys hanging out with friends.

Results from standardized evaluation indicated high-average cognitive abilities. David scored above the average range on math portions of academic achievement testing, including interactive and independent work, both timed and untimed. He did well with answering factual questions about reading passages, but he missed inferential questions. His word reading speed was very slow and he made more errors on sight words and nonsense word decoding than expected for his age. His essay was simplistic and brief, but reasonably well-organized. Results from attention testing were all in the average range for David’s age, including auditory and visual sustained attention. Behavioral observations during the evaluation included increased fidgeting and restlessness during reading and writing tasks, but good attention to the clinician throughout the lengthy evaluation. David completed the CAARS 2 via a tablet while the clinician scored his other tests. His parents each completed an Observer form remotely via an emailed link (after David signed a release of information). Results from the CAARS 2 are provided in Table 5.4.

The clinician had interpreted the CAARS 2 many times in her practice and noted the following as she lined up all three computer-generated reports (self, mother, father) and flipped through them simultaneously.

• No concerns about Response Style for self-report or father’s ratings (Validity indices were in the expected range, no omitted items, reasonable completion pace). Note mother’s Negative Impression Index was flagged; the clinician marked this to investigate further at the feedback session.
  
  
• No need for follow-up was indicated on the Associated Clinical Concern Items. No suggestion of suicidal thoughts/attempts or self-injury, no endorsement of anxiety/worry or sadness/emptiness. This was consistent with information from interviews and with the lack of elevation on the Negative Self-Concept Content Scale.
  
  
• For the scales, the self-report profile is mostly flat, other than the ADHD Index. Father’s ratings produced slight elevations around Inattention (both Content and DSM Symptom Scale T-scores). The profile emerging from mother’s ratings is similar to father’s but higher, including slight elevations for hyperactivity. Symptom Counts are consistent with the DSM T-scores for Self-Report. Mother’s DSM ADHD Inattentive Symptoms ratings are consistently elevated for both T-score and Symptom Count. Father’s T-score for DSM ADHD Inattentive Symptoms is Slightly Elevated for the age group, but the corresponding Symptom Count is low. The clinician recalled that T-scores and Symptom Counts are based on different metrics, and that this pattern corresponded with higher concerns relative to age-matched peers but low levels of DSM criteria.
  
  
• Items by Scale tables show the elevated ADHD Index scores were due to needing deadlines and reminders, difficulty concentrating on boring things, difficulty staying focused, difficulty prioritizing, procrastinating, difficulty paying attention, distractibility, and having a harder time with things than other people do. In addition to these ADHD Index items, mother’s report of inattention includes only concentrating when things are interesting, careless mistakes, and poor sustained attention. Her report of hyperactivity includes tapping hands/feet and distracting others; these items were not elevated for self-report or father’s observations.
  
  
• Responses to the Impairment & Functional Outcome Items were informative. David and his parents all indicated problems at work/school and endorsed high levels of distress and impairment (“things described on CAARS 2 bother him” and “things described on CAARS 2 interfere with his life”). David also endorsed that things are harder for him and that he feels like an underachiever. He said he “occasionally” had problems because of time spent online. His father’s ratings on these items were similar. His mother reported very high levels of concern about impairment and functional outcome, particularly problems with family relationships, problems at school, underachievement, neglecting important responsibilities, and problems with time spent online.
  
  
• David’s write-in responses to the Additional Questions highlighted specific school-related concerns (“I need help in college” and “My life is pretty good otherwise”). Likewise, his father focused on school in his responses to the Weaknesses item (“School has always been hard for David . . . if he has ADHD, we want to get him help so it doesn’t keep him from finishing college.”) and described many strengths including, “cheerful, easy-going, a friend to everyone, a natural at math, a great kid.” David’s mother wrote additional concerns, including, “After countless years of helping him with homework, I thought he had learned how to do school, but clearly he has not learned his lesson yet. This just became a very expensive lesson, it’s too late to get tuition refunded.” She described strengths as, “When I’m there to hold his hand, David can do a good job. He just needs to try harder.”
  
  
• Overall, results from the CAARS 2 Self-Report were not suggestive of ADHD other than an elevated ADHD Index. Paternal report did not strongly indicate consideration of ADHD. Ratings from David’s mother suggested the possibility of ADHD, particularly features of inattention. The clinician recalled that David’s mother had a flag on the Negative Impression Index. She calculated the statistical significance of differences between the mother’s ratings versus the self-report or father’s report (using instructions outlined in appendix I). Results showed that the mother’s ratings were much higher than David’s self-report in all Content and DSM scales (statistically significant at p < .05; with the exception of Impulsivity, which falls just short of the critical value). Maternal ratings were higher than paternal ratings for all but one scale (Impulsivity). The clinician decided to follow up on these discrepancies in the feedback meeting.

When David and his parents returned to review the results, the clinician began by asking David’s mother about some of her elevations, including items on the Negative Impression Index. David’s mother replied, “I was so upset when I filled this out; my son clearly needs help and I want to make sure he gets it. My friend said the university gave her son extra help after he was diagnosed with ADD and it really turned things around.” The clinician then met with David separately to ask for examples of the CAARS 2–ADHD Index items he endorsed. David described that those things happen “all the time” when he is reading or writing, but “rarely or never” when he is doing math, participating in labs, talking to friends, watching movies, and listening to lectures. He decided to average out the 3 (“Completely true; Very often/Always”) and 0 (“Not true at all; Never/Rarely”) and mark 2 (“Pretty much true; Often/Quite a bit”), because there was no 1.5 option, and he had a lot of reading and writing last semester. When David’s parents were brought into the conversation, they agreed with David’s rationale, saying they did see some areas where he had very good attention (e.g., coaches commenting on his great focus).

Given these clarifications in the context of evaluation data, the clinician was confident that David’s features of inattention were restricted to tasks involving reading and writing. There was no convincing evidence that he had pervasive inattention across multiple settings (social, work, academic-math). Although the CAARS 2–ADHD Index was elevated for David’s self-report, his Content and DSM scores did not have significant elevations. His mother’s ratings were tempered by a flagged Negative Impression Index. The clinician remembered the caveat from Step 5. Integrate and Compare CAARS 2 Results (Across Raters and Across Time) in chapter 4, Interpretation that all scores must be integrated and interpreted in a broader context, that no single score from a rating scale can dictate diagnosis. He remembered that the ADHD Index is intended to describe whether a person is more similar to individuals with ADHD versus the general population, not to differentiate between ADHD and other clinical diagnoses.

The clinician assigned a DSM diagnosis of Specific Learning Disorder with impairment in reading and written expression (a.k.a., dyslexia) based on David’s psychoeducational and neuropsychological test results, record review, and academic history. The clinician added a note that David may look like he has ADHD when he is faced with reading and writing demands, including procrastination, short attention span, and restlessness, but that he had many examples of intact attention, executive functioning, and self-control outside of those specific academic areas. She recommended academic accommodations (e.g., text-to-voice for assigned reading, voice-to-text for written work, extended time on tests involving reading/written language, and advance notice of assigned reading and papers), writing strategies (e.g., pre-writing with graphic organizers), and on-campus supports (e.g., Writing Center, course-specific discussion groups, and tutors).

David was able to return to college the next semester, with appropriate accommodations and supports. The clinician had a telephone follow-up with David and his parents a year later and learned that things were going much better. David’s mother said, “I wish we had done this sooner; I can’t believe I spent so many years mad at David when really he was working as hard as he could. I had no idea he was dealing with dyslexia.” David was proud to report he had successfully completed all required courses involving lots of reading and writing (with the help of his accommodations and weekly meetings with the Writing Center on campus) and was excited about focusing on his physics and computer programming classes.