Gloria, a 40-year-old married woman, was referred by her primary care physician for a post-concussion follow-up assessment. She experienced a minor concussion during a car crash last year. Her primary care provider noticed that although many of her computerized post-concussion battery scores improved in the first month following the accident, Gloria continued to show impairment in sustained attention. He referred her for a more in-depth assessment to determine if other factors were complicating her recovery. This is Gloria’s first comprehensive evaluation; she has no history of academic accommodations or mental health treatment.

This case study illustrates the following:

• Differential diagnosis of ADHD in the context of head injury; the importance of premorbid history
  
  
• Administering CAARS 2 after the diagnostic interview
  
  
• Examining T-scores that are close to the border of a score category
  
  
• Follow-up of a low-level endorsement of an Associated Clinical Concern Item
  
  
• Adult presentation without a history of childhood diagnosis
  
  

In the interview, Gloria reported that she was involved in a car crash 12 months ago when she hit black ice on an overpass, struck the guardrail, and triggered her car airbag. No other vehicles were involved, and a passing motorist called for an ambulance immediately. The emergency room physician diagnosed a mild concussion and told Gloria to follow up with the concussion clinic. Gloria recalls that she felt sluggish and out of it, saying, “It was like I was underwater, just watching everything happening around me.” She experienced bad headaches and difficulty sleeping for several weeks. Gradually, these symptoms resolved. She did not experience any symptoms of psychological trauma from the event, such as nightmares or intrusive memories of the crash. Gloria described that she had “the attention of a flea” right after the car crash, but that it had returned to normal now that her sleep and headaches have improved.

When asked about her childhood, Gloria described that she did “fine” in school. A review of report cards found in her parent’s attic revealed that she typically earned Bs and Cs and was well liked by her teachers and classmates. Gloria remembered that her parents and teachers sometimes got exasperated because of her daydreaming and forgetfulness. She often forgot to do both sides of worksheets or wrote term papers on the wrong topic, but her desire to please and sincere apologies usually led to her being given a second chance. Gloria played on a very competitive varsity volleyball team in high school, even making it to the state championship. She reported getting “bumped on the head” a handful of times during practices and matches but noted that “everybody did; it wasn’t a problem as long as you could shake it off and keep playing.”

After high school, Gloria attended a small college in her hometown. She recalled that she particularly benefited from the mandatory study hall. Gloria met her husband, Martin, during her junior year and they got married right after she graduated. They decided not to have children, and Gloria opened a small garden consulting business with a few loyal clients. She noted that Martin is supportive, but he thinks she spends too much time on her clients and charges too little for what she provides. She is often amazed by how her day flies by, finding herself scrambling at the last minute to pull dinner together because she forgot to go to the grocery store or lost track of time while checking Facebook; they often end up getting take-out or eating at a restaurant. Gloria has a good group of friends from high school who give her rides to social outings because they know she will be late if she drives herself.

After reviewing available school records and completing a clinical interview, the clinician suspected that Gloria may have had attention issues that predated any of her head injuries. He decided to complete abbreviated testing to inform the differential diagnosis of premorbid ADHD and/or neuro-cognitive consequences of head injury. Gloria was cheerful and on-task during interactive portions of the evaluation but needed reminders to keep working during subtests that required independent effort. She often asked for items to be repeated. Overall, her IQ and academic achievement scores were in the average range. The clinician obtained permission to phone Gloria’s parents so he could better understand what things were like before she began playing competitive volleyball, in order to examine premorbid presentation in case her “bumps on the head” had been unrecognized concussions. Gloria’s parents recalled that she had always been a sweet girl, but they said that “she would lose her head if it wasn’t attached.” When asked about attention and memory, they agreed that Gloria was a daydreamer who needed reminders about departure time, to the point that they routinely tell her an earlier time for family events so she won’t be late. They said right after the car crash she was “really out of it,” but otherwise she’s always been just like she is now.

The clinician asked Gloria to complete a full-length CAARS 2 Self-Report form. He asked Martin to complete the full-length CAARS 2 Observer form. The CAARS 2 results are provided in Table 5.6.

The clinician consulted chapter 4, Interpretation to help interpret Gloria’s self-reported data.

1. Response Style Analysis. The clinician noted to follow up on the Inconsistency Index score to better understand how Gloria approached completing the CAARS 2, as this information may impact how other CAARS 2 results are interpreted. All other Response Style metrics (Negative Impression Index, Omitted Items, and Pace) are within expected ranges and do not raise concerns regarding how Gloria approached completing this rating scale. He flipped ahead to the Items by Scale tables at the back of the report to see why the Inconsistency Index was flagged and saw that while Gloria “always” feels like a failure, she only “occasionally” feels like past failures keep her from believing in herself. She marked that it’s “often” hard to pay attention but “never” hard to stay focused. She said she was “never” irritated, but “often” frustrated. The clinician decided to proceed with interpretation, but to gather more information about these Inconsistency Index items when Gloria returned for the results meeting.
   
   
2. Associated Clinical Concern Items. Gloria’s responses to these items were not unusually elevated, but the clinician noticed she responded “occasionally” to the two Screening Items. The clinician made a mental note to inquire about depressive and anxious symptoms during the feedback session and to be watchful for any indication of such symptoms emerging from other components of the evaluation.
   
   
3. CAARS 2 Scales. The clinician noted that Gloria’s Inattention/Executive Dysfunction score was elevated, indicating that it is higher than expected relative to other 40- to 49-year-olds. Although technically her Negative Self-Concept T-score was in the Not Elevated category, it was just one point away from being Slightly Elevated and warrants a closer look. Her Hyperactivity, Impulsivity, and Emotional Dysregulation scores were not elevated.
   
   Overall, Gloria’s report of inattentive symptoms associated with DSM ADHD is higher than typically reported by 40- to 49-year-olds, but her report of hyperactive/impulsive symptoms associated with DSM ADHD is in the typical range for this age group. She responded “often” or “very often” to 5 of the 9 inattentive features, and 1 of the 9 hyperactive/impulsive features. This pattern of results suggests that a diagnosis of ADHD Predominantly inattentive presentation merits further consideration. It is essential to consider additional sources of information and to establish that both the symptomatic and the additional criteria specified in the DSM are met before assigning a diagnosis. Gloria’s ADHD Index probability score is in the borderline range, similar to those produced by other individuals in this age group whether they are in the General Population Sample or the ADHD Reference Sample (i.e., have been diagnosed with ADHD). Her overall profile on the CAARS 2 Scales had clear peaks associated with inattention, with borderline negative self-concept; everything else was not elevated.
   
   
4. Item-level responses. The Items by Scale tables showed a handful of 2s (“Pretty much true; Often/Quite a bit”) on the Content and DSM scales for inattention. There were some mild elevations on the Impairment & Functional Outcome Items, including that things reported on the CAARS 2 bother her and interfere with her life, problems at work/school, neglects family/household responsibilities, and problems due to time spent online. In response to the Additional Questions, Gloria wrote, “I’m lucky Martin puts up with me” and “I’m definitely always flustered, that item struck home. Wish I wasn’t always behind with housework and job invoices, the question about time online makes me wonder . . . .”

The clinician decided to postpone Step 5 (integrating CAARS 2 results across raters and across time) until he had examined the Observer report from Gloria’s husband. Once the Observer report was available, the clinician interpreted the data.

1. Response Style Analysis. No concerns about Martin’s Response Style metrics.
   
   
2. Associated Clinical Concern Items. Martin marked all four of these items as “Never/Rarely.”
   
   
3. CAARS 2 Scales. Observer ratings led to a Content Scale elevation on Inattention/Executive Dysfunction. The DSM Symptom Scale T-score was elevated for the ADHD Inattentive Symptoms scale and the DSM ADHD Inattentive Symptom Count was 6/9. The DSM Hyperactive/Impulsive scores (T-score and Symptom Count) and DSM Total Scale T-score were not elevated. The Observer-reported CAARS 2–ADHD Index was in the High range, indicating that Martin described Gloria as more similar to individuals in the clinical ADHD sample than individuals in the General Population Sample. Martin’s ratings produced an overall CAARS 2 profile that was mostly in the average range, with peaks for Content Scale Inattention/Executive Dysfunction, DSM ADHD Inattentive Symptoms, and the ADHD Index.
   
   
4. Item-level responses. A review of the Items by Scale pages showed Martin endorsed a number of items about inattention as 2s (“Pretty much true; Often/Quite a bit”), with a sprinkling of 1s (“Just a little true; Occasionally”) and no 3s (“Completely true; Very often/Always”). There were some mild elevations on the Impairment & Functional Outcome Items, including that things described on the CAARS 2 interfere with Gloria’s life, problems at work/school, harder time than other people do, underachiever, sleep problems, problems with money, neglects family/household responsibilities, risky driving, and problems from time online. Martin elaborated on many of these items in his responses to the Additional Questions. For current issues/problems, he wrote, “Gloria is very bright, and her clients are always pleased with her work, but it takes her forever to complete landscape plans and billing, like months. If her clients weren’t so loyal, they would have dropped her. Plus, she does not charge enough for what she does. There are people out there with less education and experience who are charging more. She seems to work a lot for not much compensation, staying up late to do paperwork instead of going to bed when she’s tired. Even though she only has a few clients at work, she always seems to be behind at home too. I’ve offered to hire someone to clean the house and prepare meals, but she insists on doing it herself. But then it doesn’t get done and she feels bad. Also wanted to clarify about the driving and online stuff. She has multiple scrapes and dings on her car from poles, trees, the back of the garage, the garage door, and the occasional fender-bender with people who agree to settle without involving insurance or the police. She is careful but scatterbrained. And social media is like a black hole, she goes to her office ‘for just a minute’ and she’s still reading posts from her 1,000 ‘best friends’ an hour later.” For strengths, he wrote, “Gloria struggled more in the month or two following her car crash, but she is back to her normal, sweet, lovable self now.”

After completing Steps 1 through 4 for Martin, the clinician integrated CAARS 2 findings for Gloria’s self-reported data and Martin’s observations of her.

5. Integration of CAARS 2 data. The clinician began by integrating results within the CAARS 2 Self Report. He noted Gloria’s borderline elevation of Negative Self-Concept and low-level endorsement of the anxiety and depression screening items. She had not described sadness, anxiety, or negative self-concept in her initial interview, but he decided to follow up with her during their feedback session. Otherwise, her ratings suggested features of DSM ADHD Predominantly inattentive presentation. The review of Martin’s CAARS 2 Observer ratings was also consistent with possible DSM ADHD Predominantly inattentive presentation. This pattern was evident in the Content Scales, DSM T-scores, and DSM Symptom Counts

When Gloria returned to review the results and recommendations from her evaluation, the clinician asked her about sadness, anxiety, and self-concept. Gloria shared that from time to time, she feels “less than” compared to her childhood friends who have successful careers and children. She sometimes wonders if there is something wrong with her that she didn’t go further in life, but in general, she feels happy and fortunate. She described that she occasionally feels sad or lonely, especially when Martin has to work late and she eats dinner alone. However, she “instantly feels better” as soon as she opens her social media accounts or calls a friend. She does not think she is anxious in general, but she does have moments when she worries about her parents as they grow older. The clinician followed up on Gloria’s note about feeling “flustered,” including asking about feelings of irritability and frustration (one of the flagged Inconsistency Index contrasts). Gloria rolled her eyes and said, “I think I read ‘frustrated’ as ‘flustered.’ Sorry about that! I don’t really get frustrated very much.” The clinician consulted the manual and saw that the Inconsistency Index cut-off is flagged when it is greater than or equal to 4 raw score points, so this change in ratings meant Response Style was no longer flagged as a concern.

The clinician considered the CAARS 2 results in the context of this additional information and all other data sources from the evaluation. He felt there was strong support for premorbid features of inattention and executive deficits that existed prior to Gloria’s car crash. Although it is possible that she had a series of mild concussions in high school, past report cards and interview data (with Gloria as well as her parents) suggested that her pattern of inattention, forgetfulness, and “spacing out” (i.e., daydreaming) began as early as elementary school (i.e., before concussions). Although Gloria never had formal accommodations, she received informal support throughout school. She attended a small college that provided significant structure and guidance for its students. Gloria has cultivated a strong support system throughout her life that has provided an optimized environment for her success. With the help of her parents, teachers, friends and husband, she has experienced significantly less distress and impairment.

The clinician decided to assign a diagnosis of ADHD, Predominantly inattentive presentation, noting that Gloria meets full symptomatic criteria, age-of-onset, pervasiveness, and impairment (DSM Criteria A, B, C, and D), and that he had ruled out other possible explanations such as anxiety, depression, and adult-onset symptoms secondary to a head injury (Criterion E). He noted that he suspects that distress and impairment would be more evident in a different setting, but even in this optimized setting, Gloria has impairment. The clinician communicated with the referring physician that it appeared the sequelae of Gloria’s mild concussion had likely resolved, and that the computerized post-concussion battery was flagging symptoms of premorbid ADHD Inattentive rather than persistent attention deficits from the car crash. The clinician also encouraged Gloria to pursue brief solution-focused therapy to expand her coping skills, given that she seemed vulnerable to any potential changes in her support network.