Conners 4 Manual Chapter 5: Case 2. “Emma”

Case 2. “Emma”

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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 case study illustrates the following:

• Report of internalizing problems

• Self-Harm Critical Items flagged

• Use of short forms for progress monitoring

Emma is a 14-year-old girl in the 9th grade who was referred to a school psychologist. In the initial interview with Emma’s parents, they reported that Emma has been struggling in school lately, spending less time with peers, and has difficulty concentrating. Her teachers expressed that they are unsure how to engage Emma, and she is at risk of failing classes that would need to be repeated. Her parents wanted to know if they are over-reacting to typical adolescent behavior or if there is a problem that is worthy of intervention. In talking to their friends who have children who are Emma’s age, they fear that Emma’s current despondent behavior, moodiness, and drop in grades are not typical, and they are worried about her.

Based on information from the interview, the school psychologist sent Emma’s parents links to a battery of tests for one of them to complete online (it was decided that Emma’s mother would complete the assessments, even though both parents would be present at the parent interview). This battery included the Parent forms of the full-length Conners 4 and the Conners Comprehensive Behavior Rating Scale™ (Conners CBRS®; Conners, 2008), along with a background history questionnaire. The school psychologist also sought permission from the parents to ask two of Emma’s teachers to complete the full-length Conners 4 Teacher and the Conners CBRS Teacher. The parents recommended Emma’s math and art teachers because Emma was recently struggling in math class, whereas she has always enjoyed art and continues to do well in this class.

A second interview with the parents was scheduled, as well as a half-day testing with Emma to take place a week after the parent’s interview. This week gave the raters time to complete the forms, as well as time for the school psychologist to review the results and determine if there was anything else they wanted to administer in advance of the second interview. A review of the family history revealed that Emma’s father was diagnosed with ADHD at age 9 and has been on medication since then to manage symptoms. Emma’s mother was once prescribed anti-depressants by her primary care physician, which she took for a period of approximately five months. No other mental or physical health problems were reported.

The school psychologist selected the Combined Gender Normative Sample as the reference sample to use for Emma’s score comparisons. Looking at an overview of results, the psychologist observed scale score elevations on the Conners CBRS for Emotional Distress and Major Depressive Episode, and on the Conners 4 for Inattention/Executive Dysfunction, Emotional Dysregulation, Depressed Mood, and Anxious Thoughts. In addition, there was evidence of the presence of DSM symptoms of ADHD Primarily Inattentive Presentation (4/9 as rated by the math teacher and 5/9 as rated by Emma’s mother) and Slightly Elevated scores for the DSM ADHD Inattentive Symptoms scale (T = 63). These elevated scores suggested that a closer look at executive functioning and the possible presence of depression and/or anxiety symptoms was warranted. The school psychologist asked Emma’s mother and teachers to complete the Comprehensive Executive Functioning Inventory (CEFI; Naglieri & Goldstein, 2013) to assess Executive Functioning, and for Emma’s mother to complete the Multidimensional Anxiety Scale for Children 2nd Edition™ (MASC 2™; March, 2013) and the Children’s Depression Inventory 2nd Edition™ (CDI 2®; Kovacs & MHS Staff, 2011) to further evaluate the depression and anxiety symptoms reported.

Emma visited the school psychologist’s office for in-person testing. Emma completed the same battery of rating scales given to her parents and teachers, along with performance-based tests, including the Conners Continuous Performance Test Third Edition™ (Conners CPT 3™; Conners, 2014). Several days after testing, Emma met with the school psychologist for an interview.

The Conners 4 results from all raters are presented in Table 5.3.

The school psychologist followed the Step-by-Step Interpretation Guidelines (see chapter 4, Interpretation) in preparation for the interview with Emma and her parents.

Step 1: Examine the Response Style Analysis

None of the response style metrics (Negative Impression Index, Inconsistency Index, Omitted Items, Pace) were flagged for any of the raters.

Step 2: Examine responses to Critical & Indicator Items

Emma endorsed the Self-Harm Critical Items, which were flagged for immediate review by the school psychologist. The parent interviews did not mention this concern, so the psychologist made a note to follow up with Emma on this topic during their interview.

The Sleep Problems Indicator was flagged for all raters, indicating difficulty with falling or staying asleep and appearing tired.

Step 3: Interpret scale scores

All rater’s ratings resulted in Slightly Elevated scores for Inattention/Executive Dysfunction, and Emma and her mother’s ratings also resulted in Slightly Elevated scores for Emotional Dysregulation. The Hyperactivity and Impulsivity scales scores were within normal limits (Average or Low). The Within-Profile Comparison revealed that each rater’s (i.e., mother, two teachers, and Emma) ratings led to Hyperactivity and Impulsivity scale scores that were significantly lower than each of their average Content Scale scores for Emma. In contrast, each rater’s ratings led to Inattention/Executive Dysfunction scale scores that were significantly higher than each of their average Content Scale scores for Emma. Finally, both Emma’s and her mother’s ratings led to Emotional Dysregulation scale scores that were significantly higher than Emma’s and her mother’s average Content Scale scores. These findings confirmed Emma’s relative lack of problems with regards to hyperactive and impulsive behaviors, which steered the focus of the school psychologist’s interpretation and plans for treatment priorities.

Impairment & Functional Outcome Scale scores were Slightly Elevated for the school domain for all raters. Peer Interactions and Family Life scores were all in the average range. The Within-Profile Comparison confirmed that impairment in the school domain was significantly higher than each rater’s average score for Emma, indicating that her symptoms are impairing her the most at school, relative to the other domains assessed (i.e., peers, home).

The DSM Symptom Scale T-scores related to ADHD symptoms were aligned with results from the Content Scales, in that only the ADHD Inattentive Symptoms displayed slight elevations in the T-scores and higher symptom counts across raters. Finally, the ADHD Index probability score was Borderline according to all raters, so it was not clear whether Emma was more similar to youth her age in the general population or more similar to youth diagnosed with ADHD.

When looking at the scales that assess symptoms of commonly co-occurring conditions, both Emma and her mother’s ratings resulted in clinically relevant scores for Depressed Mood and Anxious Thoughts (Very Elevated and Elevated, respectively). For all raters, scores for the DSM Oppositional Defiant Disorder Symptoms and DSM Conduct Disorder Symptoms were in the Average range.

This profile of scores led the school psychologist to continue to focus on the symptoms of depression, as well as symptoms and impairments related to attention problems.

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

Reviewing the Items by Scale tables in the report, the school psychologist observed that for the Content Scales, raters provided moderate levels of endorsement for many items in the Inattention/Executive Dysfunction scale (mostly the items associated with being forgetful, task initiation and completion, and sustained attention were endorsed), Emotional Dysregulation (with elevated item responses related to issues with getting angry all of a sudden, overreacting when upset, and mood lability), and Depressed Mood (highest ratings for items associated with seeming tired, sad, and not enjoying things the way she used to). For the Impairment & Functional Outcome Scales, the psychologist observed most of the item elevations were from the Schoolwork scale (highest ratings for items associated with handing things in late or forgetting to turn in work).

In the open-ended Additional Questions, Emma’s mother repeated the same concerns she provided during the interviews. Both teachers indicated that Emma was not a problem in the class and a pleasure to teach. However, both teachers also commented on work being submitted late, incomplete, or not at all. The math teacher said that she thinks Emma could do better if she applied herself more.

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

During the interview with Emma’s parents, the school psychologist learned she is an only child. Both parents said Emma was a happy child growing up, was always a little on the quiet side, and was a bit of a bookworm. Her grades in school were always excellent, and she enjoyed school. She had a particular interest in creative writing and art. She was never the most popular girl in her class, but she always had a small circle of close friends.

Emma started 9th grade at a new school. The first semester went well; Emma had good grades and seemed to be adjusting without any problems or concerns. Having more than one teacher (one for each subject) was an adjustment for her, relative to her previous K–8 school, and there was more homework than she was used to. However, with the help of her parents, she was able to keep on top of it all. A set time was designated after school to get homework done, and, after dinner, she would watch TV with her parents or text with her best friend.

In the second semester, Emma’s situation seemed to change as Emma began to spend a lot of time in her room and less time with her parents. She went up to her room after school to do her homework, instead of doing it at the kitchen table. She became moody and snapped at her parents if they asked her if anything was wrong of if she wanted to talk to them about anything. She shared that she and her best friend were drifting apart because her friend had made some new friends that Emma didn’t like, and as result, Emma and her friend were spending less time together. Emma also received lower scores on recent tests and lost marks for handing in assignments late. Eventually, Emma stopped sharing her test grades with her parents.

Emma’s mother indicated that she had tried everything, from encouraging Emma to get together with her friend, to urging her to give the new girls a chance, to telling Emma to come to her mother about school projects if she needed help. But the more the mother tried, the more Emma retreated. The mother thought that perhaps if she gave Emma some space and ignored the behavior, it might go away.

During Emma’s interview with the psychologist, Emma shared that her best friend’s new group of friends were fine, although Emma didn’t like them all that much. She said, “Things were great when it was the two of us, but now she hangs out with these three other girls.” Emma complained that her parents kept encouraging her to spend time with her friend and didn’t seem to understand that it meant hanging out with these other girls too, which Emma didn’t want to do.

Because of the flag on the Conners 4 Self-Harm Critical Items, the school psychologist asked Emma about her responses to these items. Emma noted that she had seen videos online of girls making cut marks on themselves. She said there was a group that posted photos of their cuts, then talked about it online, and she wanted to join in. She said her parents didn’t know she was cutting herself. She said it didn’t hurt much because she didn’t cut very deep. The psychologist also probed her response to “I have thought about hurting myself.” Emma denied any suicidal plans or attempts but said she thinks a lot about what would happen if she killed herself, describing her thoughts such as “who would come to the funeral, and stuff like that.” She said she also sometimes fantasized that if she were in the hospital, her best friend would visit her and they would spend time together—just the two of them again.

Emma said that she feels angry and doesn’t know why, and she reported that she’d rather be alone when she feels this way. She said she felt guilty about her grades and didn’t think they reflected her abilities. She said she just keeps forgetting or cannot concentrate long enough to complete or submit assignments on time.

Emma brightened when asked about her artwork. She described a painting she was currently working on but admitted she spends more time working on it than her assigned art projects for school or her other homework. She likes doing art for fun and finds it relaxing. She admitted she is a bit of a perfectionist and has thrown out or abandoned projects she has spent a lot of time on if she can’t get some part of it right. Most recently, she had to do a portrait for school, and said she spent a lot of time on the nose but couldn’t get it right. She said she finally just gave up and never submitted that project.

Results from the CEFI rating scales revealed issues with executive function and inattention, which were supported by the difficulties observed on the performance tests. Although the performance-based testing results showed average to high-average intellectual and cognitive functioning, there was some evidence of difficulties with sustained attention based on results from the Conners CPT 3. Emma was pleasant during her afternoon of testing and appropriately engaged (i.e., no failed performance validity tests, either standalone or embedded). She seemed a bit bored by the tests and asked twice how much longer she would be doing testing. Because Emma’s father was diagnosed with ADHD and it is highly heritable, it seemed possible that Emma could also have ADHD. However, it was difficult to determine if Emma was experiencing difficulties with concentration and sustaining attention due to her depressive symptoms or as a result of attention challenges.

Because the referral question concerned slipping grades, despondent behavior, and concentration problems, and because Emma admitted to self-harm behavior, the school psychologist focused on providing suggestions for addressing Emma’s depressive symptoms at this junction. The school psychologist supported Emma in telling her parents about the self-harm behavior, and together they determined that this should be the initial focus of intervention.

Emma began meeting with a clinical psychologist weekly and was enrolled in community-based group therapy sessions. Emma’s clinician used the CDI 2 Self-Report and Parent forms to monitor her progress on a monthly basis. In the school environment, accommodations were put into place for Emma. After having established an initial relationship with the school psychologist through the evaluation and interview, she continued to meet with them on a regular basis to check in. The Individualized Education Plan (IEP) team agreed to meet again in three months to review Emma’s progress, re-evaluate her school-based challenges, and determine next steps.

Follow-up

After three months of treating Emma’s depressive symptoms, the self-harm behavior had stopped and Emma had a new friend she met in group therapy with whom she enjoyed spending time. To examine the possible ADHD symptoms, the school psychologist decided to re-administer the Conners 4 to Emma, her mother, and her math teacher. Because Emma’s depressive symptoms were being monitored using the CDI 2, the psychologist decided it was unnecessary to provide the full-length form again, and instead sent a link for the Conners 4–Short to be completed online by Emma, her mother, and the math teacher.

The results of the Conners 4–Short are provided in Table 5.4. Again, the school psychologist used the Combined Gender Normative Sample as the reference sample for score comparison.

Steps 1 to 5 were repeated to review the results from the Conners 4–Short. The results indicated that Emma was still having trouble with inattention and executive function as reported by all raters. Although the pattern of results was similar to the results from the full-length Conners 4, ratings on the short form led to higher scores relative to the baseline. Emma’s mother also provided higher ratings on the Schoolwork scale, reporting more school impairment at this time, as the mother had become more aware of the extent of the problems that Emma had been previously hiding from her. The ADHD Index probability score, which was in the Borderline range at the initial evaluation for all raters, was now in the High range, indicating more similarity to youth with ADHD than youth in the general population.

The school psychologist spoke with Emma’s mother and found out that while Emma was still a bit moody and had trouble regulating her mood, she was not as socially withdrawn and was no longer cutting herself. She noted that Emma was still receiving low grades in her tests, but largely because many answers were left blank. Emma lost marks on projects for not getting her work submitted by the deadline, and teachers commented that the work was of high quality, and the low grades were only due to lateness. Emma’s mother reminded the school psychologist that she and Emma used to have a scheduled time to do homework, but managing homework was left up to Emma now. She explained that she used to keep track of her daughter’s assignments by writing deadlines on the shared family calendar and reminding Emma of due dates. Since the onset of Emma’s depressive symptoms, she left Emma alone to avoid conflict. As Emma’s symptoms improved, she explained they did not return to the former routine, and she was no longer managing Emma’s work. The school psychologist noted how the mother’s involvement had been a successful coping strategy to help Emma manage her schoolwork. However, without this intervention and left to manage time and keep track of assignments on her own, Emma was struggling.

Based on interviews and observations, as well as progress monitoring with the CDI 2, it was clear that Emma’s depression symptoms had improved markedly; however, even as she continued to show progress with her treatment in private therapy, results of the CEFI and Conners 4–Short indicated that she was still struggling with task initiation, prioritization, focus, and task completion at home and at school. Her mother reported that Emma was unsure how to organize herself, rarely started tasks on time, and did not leave enough time to complete them. Parent interviews revealed that through her early schooling years and up to the beginning of 9th grade, Emma was more successful academically because her mother provided direct coaching and daily support. This helpful intervention masked some of Emma’s attention and executive function challenges which then became evident as Emma moved into a more independent schooling environment.

Upon reviewing the data, the IEP team determined Emma was eligible to receive special education services as she was not reasonably benefiting from general education supports alone. The school psychologist recommended Emma transfer to a guided study skills class instead of study hall to learn executive function strategies that she could implement independently. Accommodations were continued for her attention challenges, and she dropped in to visit with the school psychologist as needed at school. Emma continued to meet with her clinical psychologist regularly, and her parents planned a weekly night out with Emma to spend non-schoolwork related time together.

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