Conners 4 Manual Chapter 5: Case 1: “Manny”

Case 1: “Manny”

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• Step 1: Examine the Response Style Analysis
• Step 2: Examine responses to Critical & Indicator Items
• Step 3: Interpret scale scores
• Step 4: Consider item-level responses of the Conners 4 Scales and the Additional Questions
• Step 5: Integrate results across multiple raters, with other sources of information, and monitor change over time

This chapter provides interpretation guidelines for the Conners 4th Edition (Conners 4®). The majority of this chapter focuses on how to interpret the full-length form, but relevant sections can be applied to the Conners 4th Edition Short (Conners 4®–Short) and the Conners 4th Edition ADHD Index (Conners 4®–ADHD Index). The chapter begins by describing the types of scores available when interpreting the Conners 4, as well as some key demographic variables that need to be considered. Next, the step-by-step interpretation sequence is provided. The first step involves examining the rater’s response style to determine any potential concerns about how the rater completed the Conners 4. The next step involves examining responses to the Critical & Indicator Items to determine if there are areas that need immediate attention or subsequent follow-up. The last steps involve examining the scores on all the Conners 4 scales and examining the item-level responses. A description of how to compare results across raters and over time (including how to determine statistically significant change) is also provided. As noted in chapter 1, Introduction, only individuals with the appropriate background and qualifications can interpret results from the Conners 4. See Users and User Qualifications in chapter 1 for further guidance.

This case study illustrates the following:

• Use of English and Spanish forms

• Administration of online and printed paper forms

• Disabling Self-Harm Critical Items and the DSM Conduct Disorder Symptoms scale

• Score Comparison to Multiple Reference Samples (Normative and ADHD Reference Samples)

• Use of the PROMIS® Sleep Assessments

Manny is a 7-year-old boy who was referred to the clinician by the family pediatrician for an ADHD evaluation. Manny had started school six months earlier, and his 1st grade teacher had regularly complained about his disruptive classroom behavior. Manny’s mother was concerned that Manny was having trouble managing in a structured classroom setting and was interested in possible strategies to help Manny succeed.

During their initial telephone interview, the clinician learned that aside from his mother, Manny lives with his paternal grandmother who only reads and understands Spanish, and his two brothers—one older (age 9 years), and one younger (age 4 years). After the interview, the clinician sent Manny’s mom the following links to complete the assessments online: (a) the full-length Conners 4 Parent, (b) the Comprehensive Executive Functioning Inventory (CEFI®; Naglieri & Goldstein, 2013) Parent, and (c) a background history questionnaire. The clinician sent paper forms (printed from the MHS Online Assessment Center+) for the Spanish Conners 4 Parent and the Spanish CEFI Parent forms for Manny’s grandmother to complete. Paper forms were sent because Manny’s mother noted that her mother-in-law would be more comfortable with paper forms than filling in the assessments online. The clinician also asked Manny’s mother if she would be comfortable having his teacher complete ratings of Manny, and if so, if the teacher would be willing to share their email address with the clinician so that the teacher could be sent a link to complete the Conners 4 and CEFI Teacher forms online. After the teacher agreed, the clinician sent the teacher links to the two forms.

Based on the initial call with Manny’s mother, the clinician opted to disable the Self-Harm Critical Items and the DSM Conduct Disorder Symptoms scale (see chapter 2, Administration, for more information on administration options) as there was no indication of any such behaviors or concerns.

A clinical interview with Manny’s mother was scheduled for one month after the initial phone call to allow time for all raters to complete the forms and for the clinician to review the results in advance of the interview. The clinician also scheduled a half-day of testing with Manny. For the Conners 4, the clinician opted to use the Combined Gender Normative Sample as the reference sample for score comparisons. Table 5.1 presents the Conners 4 results from the different raters. For ease of use, elevated scores are shaded within the tables.

The clinician followed the Step-by-Step Interpretation Guidelines (see chapter 4, Interpretation) in preparation for the parent interview.

Step 1: Examine the Response Style Analysis

There were no flags for any of the response style metrics (Negative Impression Index, Inconsistency Index, Omitted Items, Pace) for any of the raters. Note that Pace was not an available metric for Manny’s grandmother’s ratings as she completed paper forms.

Step 2: Examine responses to Critical & Indicator Items

Based on the clinician’s selected administration options, the Severe Conduct and Self-Harm Critical Items were not administered and therefore did not appear in the report.

The Sleep Problems Indicator was flagged by both Manny’s mother and grandmother. The items “Has trouble falling or staying asleep” and “Seems tired”were rated as “Pretty much true (Often/Quite a bit)” by both raters. The teacher’s response to item “Seems tired” was also flagged. The clinician noted that it would be important to follow up about potential sleep problems during the interview. Thus, the clinician sent Manny’s mother a link to complete a sleep problems measure (the PROMIS Sleep Disturbance Short Form-8a and the PROMIS Sleep Impairment Short Form-8a; Yu et al., 2011) so that more information about sleep problems would be available at the time of the interview. Because sleep problems can mimic or exacerbate symptoms of ADHD, it was important to the clinician to fully explore the impact that Manny’s sleep problems may have.

Step 3: Interpret scale scores

Based on the clinician’s selected administration options, the DSM Conduct Disorder Symptoms scale was not administered and therefore did not appear in the report.

The ratings of Manny’s mother resulted in Elevated to Highly Elevated scores in Inattention/Executive Dysfunction, Hyperactivity, and Impulsivity. These were corroborated by both his grandmother’s and teacher’s high scores on the same scales, except for Impulsivity, in which his grandmother’s ratings led to a Slightly Elevated score. No other Content Scales demonstrated elevated scores. The Within-Profile Comparisons for all three raters indicated that the Inattention/Executive Dysfunction and Hyperactivity scales were significantly higher than Manny’s average Content Scale score, while the Emotion Dysregulation scale was significantly lower than his average score. These results suggest that Manny’s lack of emotional dysregulation may be used as scaffolding from which to build upon in addressing his difficulties with attention, executive functioning, and hyperactivity.

The Impairment & Functional Outcome Scales were within normal limits as rated by Manny’s mother and grandmother. Peer Interactions was Very Elevated as rated by the teacher, with significant difficulties also noted in the school setting. The lack of elevation for the Family Life and Peer Interactions scales by Manny’s mother and grandmother was noted as something to follow up on during the interview. For all raters, the Within-Profile Comparisons did not identify any significant differences from Manny’s average score for these scales.

The DSM Symptom Scale T-scores related to ADHD symptoms were largely aligned with the elevated Content Scale scores (i.e., scores were in the Elevated or Very Elevated range), as was the Total ADHD Symptoms scale. The Conners 4–ADHD Index was in the Very High range for all raters, indicating the profile is highly similar to scores of youth the same age who have been diagnosed with ADHD.

When looking at the scales that assess symptoms of commonly co-occurring conditions, the scores for all three raters for Depressed Mood, Anxious Thoughts, and DSM Oppositional Defiant Disorder Symptoms were all in the Average range. This information confirmed to the clinician to continue to focus on symptoms and impairments related to ADHD.

Step 4: Consider item-level responses of the Conners 4 Scales and the Additional Questions

The clinician reviewed the Items by Scale tables in the report. For the Content Scales, they observed that all three raters had moderate to high levels of endorsement (with many Elevated items) for most features of inattention, hyperactivity (verbal and behavioral), and impulsivity (verbal and behavioral). For the Impairment & Functional Outcome Scales, there were very few item elevations from Manny’s mother or grandmother, while nearly all items were Elevated for his teacher.

In the open-ended Additional Questions, all raters noted that Manny is a fun-loving child with a happy demeanor and a lot of energy. The teacher expressed their concern regarding peer rejection and disruption in the classroom, stating, “He’s bouncing off the walls and is never in his seat.”

Step 5: Integrate results across multiple raters, with other sources of information, and monitor change over time

The ratings from Manny’s grandmother were slightly more moderate compared to the ratings from his mother and teacher, although there was clear consistency across raters regarding problem areas (i.e., behaviors related to inattention, hyperactivity, and impulsivity). An exception to this pattern was the Impairment & Functional Outcome Scales, where only the teacher suggested significant concerns in school functioning and peer interactions.

Because there was still information outstanding, a full integration would have to wait until all information was collected (results from both the testing with Manny and the parent interview). In the interim, however, the clinician decided to re-score the ratings by adding a second reference group, specifically, the ADHD Reference Sample Gender Specific–Males, given the very elevated ratings provided by Manny’s mother and teacher (see Table 5.2 for the results). The clinician wanted to explore whether Manny’s behavior was typical or elevated when compared to 7-year-old boys diagnosed with ADHD .

Steps 3 to 5 were repeated using the scores obtained when compared against the ADHD Reference Sample. A review of the results suggested that compared to a sample of same-aged boys with a diagnosis of ADHD, the scores were in the average range, with some of the teacher ratings resulting in slightly elevated scale scores.

Before the parent interview, the clinician was given the opportunity to speak with Manny’s teacher. During the interview, the teacher reiterated that they thought Manny was a happy kid and likeable, although his behavior is too much to handle in a regular classroom because he takes up too much of their time at the expense of time spent with other students. When asked to elaborate on peer interactions, the teacher noted that the other kids seem to avoid Manny and complain that Manny is bothering them. Manny is often left to play by himself during recess as the other kids don’t include him in their games. Manny doesn’t seem too troubled by this exclusion and finds ways to entertain himself during recess. He likes playing on the playground equipment, particularly the twisty slide. The teacher emphasized, “Manny really is a happy-go-lucky kid, but he has too much energy for the classroom and can’t seem to pay attention to anything for any amount of time.” Given the class size, the teacher expressed hope that Manny could be moved to another classroom where he could receive one-on-one attention without it taking away from the time the teacher has for other students.

During the parent interview, the clinician learned that Manny’s father died from a workplace accident two years ago, and since that time, Manny’s paternal grandmother has been living with the family to help out. Manny’s mother worried that perhaps his behavior was in some way related to the loss of his father and their Spanish-speaking grandmother coming to live with them. There was no history of ADHD in the family as far as she was aware, although Manny’s grandmother constantly refers to how much Manny reminds her of Manny’s father at his age. Manny is in good physical health and there were no pregnancy or birth complications reported.

Manny and his older brother are good friends, and they generally get along well. Neither of the two boys pay much attention to their younger brother, but they are kind to him. Manny was described as a happy kid and is full of energy. When asked about how he dealt with the loss of his father and his grandmother coming to live with them, Manny’s mother reported that while he was very sad, cried a lot at the time, and sometimes still asked about his father, he seemed to understand that his father wasn’t coming home. He loves his grandmother and enjoys having her in the house. He likes trying to help her learn and practice English.

The clinician noted the Very Elevated Peer Interactions score indicated by the teacher, which was a result of particular item-level elevations related to Manny not getting invited to play with others, being annoying to peers, and peers complaining about his behavior. Manny’s mother said she was disappointed to learn that Manny was having problems with peers at school and that he didn’t seem to be making friends. She said that Manny hadn’t said anything to her about problems with the kids at school. She did note that Manny doesn’t have many friends because his Kindergarten year was done virtually (online) due to the COVID-19 pandemic, limiting his opportunity to get to know the other kids in his class. Virtual Kindergarten was not very successful for Manny. He had trouble engaging and often wandered off to do something else instead of paying attention to the activity or lesson on screen. The exception was sing-along time, which he thoroughly enjoyed, especially when there were dance moves associated with the song. She explained that they live in a rural neighborhood, so there are not a lot of neighborhood kids to play with (in part why Manny and his brother are so close). She was hoping that in-person learning for Grade 1 would mean that he would make friends and have playmates other than his brother. The clinician felt that the teacher’s ratings about Manny’s peer relations were very important as the past month had been the first time Manny could be observed in a peer setting (i.e., the classroom and schoolyard).

The clinician also wanted to explore possible impairment in the family setting in more detail. Looking at the item responses, Manny’s mother rated “Disrupts family activities” as “Pretty much true (Often/Quite a bit)” but otherwise, all items were rated as “Not true at all (Never/Rarely)” or “Just a little true (Occasionally).” Manny’s mother reported that while Manny has a lot of energy, he has trouble transitioning from one activity to another and doesn’t always seem to be listening. This makes it hard to get out the door on time in the morning (for example), although she commented, “What mother of three young boys is able to get out the door on time?” His talkativeness was not considered a problem in the family. She said they all talk too much, too quickly, and talk over each other. She laughed and said shouting is the normal volume in her household.

She also said that Manny is a smart kid, noting that he learned his ABCs and 123s early, and he has no issues reading and spelling basic two- and three-letter words. He loves playing outside, often engaging in make-believe play, where he is a dragon trainer (he really likes dragons). He has a slight speech impediment (he has trouble with R’s and S’s) that she hopes to have addressed through speech therapy. Family members understand him, and teachers report understanding him most of the time. The clinician followed up on the sleep problems that were indicated on the Conners 4 and the follow-up PROMIS sleep questionnaires. Manny’s mother admitted that bedtime was a problem; Manny often stalls and the bedtime routine takes forever, which ends up with everyone frustrated. Once asleep, Manny often wakes up in the night complaining of nightmares and then has trouble getting back to sleep, which often results in him being tired during the day.

While Manny’s mother knew her son had high energy levels, she didn’t anticipate the problems being reported by the teacher. She indicated that since the start of the school year, the teacher very often reported to her that Manny was talking out of turn, interrupting other kids when it was time to do work, and couldn’t sit still at his desk or during circle time on the carpet. He would poke and bother the other children or get up to wander around the classroom. The teacher suggested that Manny might benefit from more one-on-one instruction that could not be provided in the classroom. As a result, the mother consulted with the family pediatrician who made the referral for an in-house evaluation. Manny’s mother admits that he has a lot of energy, but she didn’t realize how disruptive it would be in the school setting or that he was that much different from most seven-year-old boys (noting that her eldest son is equally high energy, but teachers never had any concerns). She didn’t like the idea of moving Manny to a special education classroom, but she was willing to consider it if the clinician agreed with the teacher that it could be in Manny’s best interest.

With respect to executive function issues, she was not surprised to learn of the higher scores for Inattention/Executive Dysfunction. She noted that since starting school six months ago, Manny had already lost his baseball cap three times (later found it in the lost-and-found), left his lunchbox at school two or three days per week instead of bringing it home, and lost his water bottle monthly (which she had to replace).

During testing, Manny was engaged and enthusiastic about the tasks he was asked to do. He had trouble sitting still and was constantly squirming and changing position in his chair (getting up on his knees, sitting cross-legged in the chair, or swinging his legs when seated properly). He was talkative and told silly jokes and seemed to enjoy the clinician’s undivided attention. During testing, he required several reminders to get back on task because he often got distracted by something in the room and ended up talking about it or getting up to get a closer look. Testing showed that Manny is in the high average range for cognitive and intellectual functioning.

Based on the clinical interview with Manny’s mother, testing with Manny, and a review of scores from the rating scales completed, the clinician determined that the results are consistent with those seen in youth the same age who are diagnosed with ADHD Combined Presentation. Many inattentive, hyperactive, and impulsive symptoms were reported in both home and school settings (albeit to a greater degree by the teacher). The number of DSM criteria endorsed as “Pretty much true (Often/Quite a bit)” or “Completely true (Very often/Always)” for both inattentive and hyperactive/impulsive symptoms exceeded the number of symptoms required for an ADHD Combined Presentation diagnosis. Additionally, the T-scores relative to the Combined Gender Normative Sample suggested that the behaviors were present to a degree that is inconsistent with typical developmental levels. T-score comparisons to the ADHD Reference Sample were in the Average range, indicating that the profile of scores was consistent with what is typical of youth the same age and gender with an ADHD diagnosis. Impairment was seen in school and with peers and there were reports of difficulties at home, although not enough for a scale score elevation. Ratings from the CEFI corroborated the results with evidence of difficulties in attention, inhibitory control, self-monitoring, organization, and working memory.

During the feedback session with Manny’s mother, the clinician provided strategies and recommendations for the home setting. The clinician suggested that the behavioral interventions may work best when paired with medication. Manny’s mother said she would prefer to see how the behavioral interventions worked before considering medication. She expressed hope that Manny might settle down once he got more into the routine of school. She agreed that if Manny did not show a marked change in behavior after a few months, she would speak with his pediatrician about medication options. The clinician also discussed the importance of sleep hygiene and made suggestions to improve Manny’s current bedtime routine, which would help him get the rest he required in order to attend to the tasks of the day ahead.

Manny’s parents provided the clinician’s report to the school psychologist. The school psychologist talked with Manny’s classroom teacher and made a referral to the school’s intervention team. The team reviewed the report, Manny’s performance in the school environment, and his social history, and recommended general education intervention supports and a behavior plan for the classroom. They also planned to meet again within four months to monitor Manny’s progress, investigate intervention fidelity, adjust the plan as needed, and determine if further formal evaluation should be conducted.

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