Chapter 5: Case 3. "Asher"

This case study illustrates the following:

• Use of both full-length and short forms

• Report of externalizing problems

• Flag for Negative Impression Index

Asher is a 9-year-old boy who was referred for evaluation because of numerous temper outbursts, non-compliance, and behavior problems, both in schooland at home. Asher’s parents and teachers were struggling to manage his behavior and were worried about him. The clinician scheduled an initial interviewwith Asher’s parents. Because the two parents are divorced, do not get along, and were unwilling to attend the interview together, separate interviews werescheduled. Prior to the parental interviews, the clinician asked both parents to complete a background history questionnaire online and to provide Asher’spast and current school records to help evaluate academic performance. The clinician also scheduled time with Asher for an interview and testing.

At the initial interview with each parent, it was revealed that Asher’s mother and father divorced when he was a toddler, and that the parents haveshared custody of their children. Asher and his older sister (age 11) rotate between living one week with their mother and one week with their father. Theparents live near each other and the school, and the children are able to walk to school from either parent’s house. With respect to family history,Asher’s sister was diagnosed with ADHD Primarily Inattentive Presentation when she was Asher’s age. After learning about his daughter’s ADHD, Asher’sfather decided to have his own evaluation done. He was diagnosed with ADHD Combined Presentation and was prescribed medication. Asher’s sister is nottaking medication for her ADHD, but an IEP is in place at school to provide her with special education services.

According to Asher’s mother, Asher was a difficult child from the beginning. While there were no difficulties with the pregnancy, she reported thatAsher had been hard to manage from birth. Asher was a colicky baby. This challenge resulted in Asher’s father retreating, often finding reasons to stay outor to work late to avoid what the parents referred to as “scream o’clock”that lasted from about 5:00 p.m. to 9:00 p.m. daily. Asher’s mother said she was awreck by the time Asher was 12 weeks old. She felt alone, exhausted, and broken. As a toddler, Asher’s difficult behavior persisted. He had a lot of energyand temper tantrums were a daily occurrence. Nap time didn’t really exist for Asher. His mother had no relief or downtime as a result and was regularlystressed. As Asher developed, he continued to have a high energy level and was a “storm of emotions,” as his mother put it. He was easily distracted,impulsive, and never spent long on any single activity. While his high energy and emotional fluctuations were hard to manage, it was his uncooperativenessand hostility towards his sister, parents, teachers, and even the other kids at school, that became the bigger problem. Asher, as his mother put it, wasjust a hard kid to like. Asher’s mother admitted that she looked forward to the weeks Asher was with his father because she honestly needed the break.Asher’s mother noted that she thinks his father has an easier time with Asher simply because he lets Asher get his own way to avoid having to deal with hisoutbursts. She says she sometimes wishes she were more like Asher’s father to avoid the yelling and constant disruption, but she felt like a bad parent ifshe gave in. In his interview, Asher’s father expressed similar concerns as Asher’s mother; however, his descriptions were a little more positive, sayingthings like Asher was“strong-willed” and “knows his mind.” The clinician made a note of the inconsistent parenting styles, highlighting the strong effectthis discrepancy could have on Asher’s behaviors and development.

A review of his report cards showed that Asher received average grades. Many teachers noted that he was “too smart for his own good” and complainedabout his disruptive behavior.

On the scheduled testing day, Asher was asked to complete a battery of tests that included cognitive and academic tests, as well as the Conners CPT 3(Conners, 2014). Because of concerns with non-compliance, the Pediatric Performance Validity Test Suite (PdPVTS; McCaffrey et al., 2020) was alsoincluded to evaluate his compliance with test demands. Throughout the evaluation, Asher wasn’t very interested and was uncooperative with the tasks. Duringthe cognitive and achievement testing, Asher seemed to persist on tasks he found easy, but he disengaged as soon as difficulty increased. He couldsometimes be prompted to persevere, but not often. Results of the cognitive, academic, and achievement tests were in the average range. However, theclinician noted that the scores likely underrepresented his true ability level because he failed 3 of the 5 PdPVTS tests (indicating that Asher wasproviding suboptimal performance), and during the few times he was able to re-engage and attempt more difficult questions, he got them right.

During his interview, Asher told the clinician that he gets into trouble a lot at school, but that it is not his fault. He says he gets blamed forthings that other kids have started. He also complained that school doesn’t make sense to him, explaining that the whole concept of school is wrong. Hedoesn’t like that “they teach stuff and we are all supposed to just believe everything the teachers say.” He says that he often gets in trouble fordisagreeing with his teachers or pointing out when they are wrong.

After all interviews were conducted, the clinician requested that both parents complete behavior rating scales, which included: (a) the Conners CBRS(Conners, 2008) to assess social, emotional, behavioral, and academic functioning; (b) a comprehensive measure of executive functioning (CEFI); and (c) amore narrow-band ADHD assessment (i.e., the full-length Conners 4), as the behaviors being reported seemed consistent with ADHD symptoms and there was afamily history of ADHD. The clinician also asked Asher’s parents to ask his classroom teacher to complete ratings of Asher. After the teacher agreed, theclinician sent the teacher links to complete both the Conners CBRS and the full-length Conners 4 online. Finally, the clinician considered having Ashercomplete the Conners 4 Self-Report but wasn’t convinced that he would cooperate based on observations of Asher and from the interview with his parents.Interestingly, when Asher found out that his parents were answering questions about him, he insisted on knowing what they were being asked. The cliniciantold Asher that he could complete his own self-report and explained that the questions he would be answering about himself would be very similar to theones his parents were being asked to answer. Asher was given the Conners 4–Short to complete in-person (i.e., in the clinician’s office).

The results from the CEFI indicated problems with executive function, particularly inattention. Results from the Conners CBRS indicated multipleelevations across social, academic, and behavioral domains across raters. Most prominent were Defiant/Aggressive Behaviors, Hyperactivity/Impulsivity, andSocial Problems. The results of the Conners CBRS were corroborated with the Conners 4 results (provided in Table 5.5). For the Conners 4, the clinicianopted to use the Combined Gender Normative Sample as the reference sample to use for score comparisons.

Table 5.5Conners 4 Results: Case Study #3–“Asher”

Note. Principal Reference Sample = Normative Sample–Combined Gender. = Follow up is recommended.

The clinician followed the Step-by-Step Interpretation Guidelines as outlined in chapter 4, Interpretation.

Step 1: Examine the Response Style Analysis

The response style analysis revealed that only Asher’s mother’s ratings resulted in a flag on the Negative Impression Index, suggesting that a morenegative clinical picture than is warranted and/or symptom exaggeration was being presented. A quick look at the scale scores reveals that there was quitea number of scores that exceeded a T-score of 80 or even 90 (in rare instances). These scores represent three to four standard deviations above the mean.While not impossible, such scores are relatively rare. Asher’s mother’s responses might be affected by an overly negative response style. This responsestyle was taken into consideration during the interpretation of the other scales. No other flags existed for any of the other raters.

Step 2: Examine responses to Critical & Indicator Items

None of the Critical or Indicator Items (Severe Conduct, Self-Harm, Sleep Problems Indicator) were flagged based on ratings by any of the raters.

Step 3: Interpret scale scores

The scale scores for the Inattention/Executive Dysfunction, Hyperactivity, and Impulsivity were in the Very Elevated range across raters, with theexception of Asher’s self-reported results, in which all scores were within normal limits. The Within-Profile Comparison for all raters revealed that forthe Content Scales, there were similarly high levels of hyperactivity, impulsivity, and emotional dysregulation, while scores were significantly lower thanAsher’s average for Inattention/Executive Dysfunction (although this score was still in the Very Elevated range). This profile reveals that while all areaswere problematic, the raters indicated that Asher’s hyperactivity, impulsivity, and emotional dysregulation problems were significantly worse than hisproblems with inattention and executive dysfunction.

For the Impairment & Functional Outcome Scales, both of Asher’s parents indicated Very Elevated levels of impairment at school, with peers, and at home.Similarly, the teacher also noted impairments at school and with peers; however, all of Asher’s self-reported scores were in the Average range. TheWithin-Profile Comparison revealed that Asher’s mother’s ratings led to significantly higher ratings for the Family Life scale, indicating more impairmentat home, than at school or with peers. However, Asher’s father did not have the same results (i.e., there were no significant differences between scales).The teacher’s ratings and Asher’s ratings did not lead to significant differences from their average 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 VeryElevated 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 washighly 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, only the scores for DSM Oppositional Defiant Disorder Symptomswere in the Very Elevated range for all raters. The other scale scores (i.e., Depressed Mood, Anxious Thoughts, and DSM Conduct Disorder Symptoms) werein the Average range for all raters.

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

At the item level, the ratings were also very consistent across the parent and teacher raters (albeit with Asher’s mother nearly always rating at theextreme). The full spectrum of symptoms and impairments were rated as elevated, accounting for the Very Elevated scale scores. Note that, in contrast tothe other raters, Asher’s self-reported ratings did not lead to any item-level Elevations.

In the open-ended Additional Questions, the parents reiterated what they had expressed during the initial interview. Asher is overall a good child, buthas a lot of energy, has problems with his temper and is frequently non-compliant. Asher’s teacher expressed their concern regarding Asher’s problems withgetting along with peers and being uncooperative in class. The teacher also stated that, “Asher is a smart student, and he can do really well if only hesets his mind to the task at hand.”

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

While Asher’s mother’s scores were unusually high for some scales, the problems she reported were corroborated by his father and teacher, albeit to aslightly lower (and perhaps more realistic) degree. The results from the Conners CBRS and interviews with the parents suggested significant behaviordifficulties. The Conners 4 provided a thorough look into the externalizing problems, while also providing insight into the emotion regulation problemsAsher experienced and the ways that it was impacting him and those around him at school, with peers, and at home. Asher’s self-reported results did notalign with the results from his parents and teacher. During the clinical interview, while he admitted to some of the problems that occur and acknowledgedthat he does get in more trouble than other kids, this behavior is not the picture he painted in his self-reported ratings. The clinician followed up withAsher to find out more about the low ratings he provided. During that conversation, it was revealed that Asher felt that his parents and teachers wouldjust say bad things about him, and he wanted to make sure another view of his behavior was shared, suggesting that Asher tried to minimize hisproblems.

Combined with all other information, the scores across parent and teacher raters for the Conners 4 Content Scales, DSM Symptom Scales, and the ADHDIndex suggest that Criterion A for both DSM ADHD Combined Presentation and Oppositional Defiant Disorder were met.

The clinician felt it was somewhat notable that the hyperactive and impulsive symptoms were the highest scale elevations across raters. This pattern isconsistent with many children diagnosed with ADHD and Oppositional Defiant Disorder, where the misbehavior seems to be less due to being intentionallyoppositional and more about the inability of the youth to control their impulses.

The information was included in the clinician’s report, which the parents shared with the school psychologist. Based on this report, the schoolpsychologist suspected that Asher might have a disability; therefore, with the parents’ consent, a special education evaluation was conducted. Testingresults revealed that Asher met school-based eligibility criteria for a disability and an individualized education plan was built to support him in theschool environment.

In addition to the services and accommodations in his IEP, the clinician determined that meeting weekly with Asher and his parents for family therapywould be an appropriate treatment for Asher's oppositional behavior concerns. Asher's mother would benefit from learning to manage and de-escalate conflictand his father would benefit from creating more structure and consistency around rules and expectations. The clinician also recommended a medicationevaluation because Asher's impulsivity and difficulty sustaining attention made it difficult for him to focus during therapy sessions and was alsoaffecting his behavior and performance at school. The clinician made a referral to a child psychiatrist to evaluate medication options, started meetingweekly with Asher and his family, and scheduled a follow-up evaluation in three months’ time to assess Asher's progress.

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