At the time of this evaluation, Anthony, a 28-year-old man, was facing misdemeanor charges, with no prior criminal history. The public defender requested an evaluation to determine whether additional factors might be relevant to Anthony’s upcoming hearing given observations of impulsivity, restlessness, and short attention span. There was no known history of evaluations or diagnoses. There was no indication of substance abuse, and Anthony did not appear to be under the influence when arrested.

This case study illustrates the following:

• Use of the CAARS 2 in a correctional setting
  
  
• Paper administration
  
  
• Using an Additional Reference Sample
  
  
• Time-sensitive interpretation of results in the absence of corroborating observer reports or records
  
  

Anthony was arrested on a Friday afternoon when he shoved a police officer during a brawl that erupted outside the local community center. He was held in the county jail because nobody came to pay his bail. During the first 24 hours of detention, Anthony became increasingly loud and angry, shouting that it was unconstitutional to prevent him from smoking, despite being informed that no nicotine products were allowed inside the detention center. He seemed restless, pacing around his cell. He was very chatty with others being detained, quick to engage them in conversation about sports and local restaurants, but quickly angered when confronted with different political views. He was placed on restricted status as a consequence of antagonistic comments to prison staff. The public defender met with Anthony on the Monday following his arrest, noticed his agitation and lack of focus, and referred him for an evaluation to be completed before the upcoming hearing for assaulting an officer. The public defender indicated that this evaluation could be funded through the warden’s new mental health initiative to improve compliance and reduce recidivism by providing appropriate identification and support. The public defender specified that he wanted to know if there were any diagnoses that could help explain Anthony’s behaviors, as well as any interventions that could improve his transition back into the community.

During her interview, the clinician observed the same restlessness described by prison guards and the public defender. She noted that Anthony often shifted position in his chair, drummed his fingers on the table, and rapidly bounced his leg up and down. He attempted to answer her questions, but his responses tended to include more information than she needed and were tangential. Anthony often kept talking without pausing, interrupting, and talking over the evaluator. She found that Anthony generally did not seem bothered by her efforts to redirect him and that the interview proceeded more efficiently when she asked questions that were short and focused rather than open-ended. Although Anthony rambled, his answers were coherent and logical. He was mad about being detained but was not threatening toward the clinician.

Anthony described growing up in his grandmother’s home, along with several of his cousins. His mother stayed with them at times, but his grandmother raised him. Anthony remembered that “No matter what I did, and I messed up a lot, Grams always gave me a hug and tucked me in at night.” When asked about school, Anthony said, “I wasn’t much of a student . . . spent more time with the principal and the [school resource officer] than in class.” He explained that he tried to listen in class but found it hard to resist the laughs he got for imitating the teachers. He said, “I felt bad when I saw the teacher’s face, and I hated disappointing my Grams. I always meant to do better the next time, but then the teacher would go and do something ridiculous, and I couldn’t help myself.” He said he was always passed along to the next grade “because the teachers didn’t want to have me twice,” but he did not get any special help or services in school. Anthony completed high school because it was important to his grandmother, but he had no interest in college. Anthony attended church with his grandmother every Sunday, where everyone told her what a fine grandson he was. One of the church members invited Anthony to help out at his auto repair shop after school, so he started working there after graduation. He said, “It’s a good thing Tom knows my Grams, cuz he would’ve kicked me to the curb if not.” When asked why, Anthony clarified that on occasion he overslept or forgot when it was his day to open the shop. After he left the shop unlocked one night, he was never assigned to the closing shift again. When asked about friends, Anthony said, “Yeah, I had my crew, but those lazy SOBs didn’t even bother to come bail me out. Some friends they are.”

Given Anthony’s background and current presentation, the clinician wondered if he might have unrecognized ADHD. Anthony agreed to complete the CAARS 2 paper form (as he did not have access to an electronic device while in the detention center). The clinician attempted to obtain observer ratings from Anthony’s grandmother, but she did not respond to phone messages or emails, and there was not time to contact her by postal mail before the hearing. Results from the CAARS 2 Self-Report are provided in Table 5.5.

The clinician followed the CAARS 2 Interpretation Guidelines (see chapter 4, Interpretation) for Anthony’s self-reported data, choosing the ADHD Reference Sample–Combined Gender as an Additional Reference Sample for comparison.

1. Response Style Analysis. No concerns were indicated for Response Style. Because Anthony completed the paper form, Pace was not available.
   
   
2. Associated Clinical Concern Items. No concerns were reported.
   
   
3. CAARS 2 Scales. Most of Anthony’s Content Scales are elevated relative to the General Population Sample, and some are high even in comparison with the ADHD sample. Consistent with the confidence he displayed during his interview, his Negative Self-Concept score is not elevated. His DSM Symptom Scale T-scores and Symptom Counts are elevated. Given this pattern, it is not surprising that his ADHD Index probability score is elevated. The overall profile is consistent with high elevations for scales related to ADHD.
   
   
4. Item-level responses. The Items by Scale tables show Anthony rated many (but not all) items as 2 (“Pretty much true; Often/Quite a bit”) or 3 (“Completely true; Very Often/Always”). He endorsed high levels of all DSM symptomatic criteria. His responses to the Impairment & Functional Outcome Items included problems with romantic relationships, school/work, money management, and risk-taking. He used the Additional Questions space to express strong opinions about police brutality, but no specific symptoms.
   
   
5. Integration of CAARS 2 data. Overall, data from Anthony’s CAARS 2 Self-Report are cohesive, presenting a consistent picture of inattention, executive dysfunction, hyperactivity, impulsivity, and emotional dysregulation. In addition to higher scores than typical for the General Population Sample, some of these areas are also elevated in comparison with the ADHD sample.

Based on available information, the clinician concluded that Anthony presented with most of the DSM symptoms of hyperactivity and impulsivity, including fidgeting, squirming, restlessness, excessive talking, blurting out responses, difficulty waiting his turn, and conversational interruptions. She added her observations that Anthony impulsively grabbed her pen when given paperwork, and he seemed to have difficulty staying on task while completing the CAARS 2 (including making off-topic comments to her, making sound effects, humming, and whistling under his breath). Furthermore, he presented with some features of inattention, including overlooking important details, difficulty sustaining attention in the interview, and being easily sidetracked. A follow-up interview suggested that these symptoms have interfered with Anthony’s functioning, including recurring disciplinary issues in the school setting during childhood and adolescence, frequent break-ups with girlfriends in response to impulsive and impatient actions, and inconsistent employment due to poor time management and attention to detail. Although Anthony’s self-reported history of impairment in the school setting even in elementary school suggested that these concerns began before he was 12 years old, the clinician was reluctant to make that assumption without collateral evidence from records that were not available at the time of the evaluation. She felt confident that the symptoms were present across multiple settings, given his report, her observations, and staff reports during his detention. The clinician rejected other possible mental health diagnoses. She was not able to eliminate possible medical factors that could cause or exacerbate symptoms of ADHD, such as head injury or lead exposure in childhood. After weighing confirmed information versus uncertainties, the clinician proceeded with a DSM diagnosis of Other Specified ADHD pending secondary informants and/or record review. Her written summary for the court included a recommendation for medication consultation, noting that Anthony’s presentation is moderate to severe (when compared to the ADHD sample).

The prosecutor took this mental health treatment information into consideration and offered a plea agreement for probation, with the condition that Anthony must participate in 60 hours of community service, attend an anger management group, and comply with all recommendations of his assigned outpatient mental health provider at the Community Hospital. Anthony is scheduled to return in six months for a follow-up hearing to determine if he met the conditions for reduced charges.