ADHD Case Studies

CHILD ADHD EVALUATION

REFERRAL INFORMATION

Client is an 8 year old white female referred for ADHD and emotional difficulties.  She has had trouble staying focused and on taks, sitting still, getting easily distracted, remembering what was asked, remaining in her seat, and being overly active.  She also makes careless mistakes, struggles to complete chores and schoolwork, starts tasks but quickly gets sidetracked, procrastinates, and has trouble with organization and meeting deadlines.  Client is often fidgety, blurts out answers, has trouble waiting her turn, and interrupts others in addition to having a low frustration tolerance and anxiety about her inability to focus.

Client was delayed in potty training.  She lives with her parents and younger sisters and has strained interactions with her father due to a previous traumatic experience as well as her middle sister.  Socially, Client gets along well with peers and easily makes and keeps friends.  However, she is very sensitive to negative feedback or behavioral interactions with others.

Client maintains good grades and behavior at school but has issues completing tasks and schoolwork and needs frequent reminders to finish her work.  She reportedly feels social pressure to refrain from fidgeting or getting distracted.  Teacher notes often mention talkativeness or needing help staying on task.  She was previously tested for gifted placement.

Client participated in play therapy in the past and was diagnosed with encopresis from ages 3-6 or 7.  She has trouble with changes in routine, making eye contact, and sensory interactions.  Due to the traumatic experience with her father, she feels anxious at the thought of getting in trouble, feels upset when reminded, feels jumpy, and avoids certain reminders.  However, other PTSD symptoms were denied.  Behaviorally, Client was very shy but became more open, friendly, and talkative.  She second-guessed herself often and stood often during testing.  She worked slowly, became increasingly more fidgety as testing progressed, had trouble remaining seated, and made odd, jerking motions repeatedly.

For this client, it is important to determine the timeline of attention deficit and whether they have been more longstanding or have occurred following her traumatic interaction with her father.  This helps distinguish between true ADHD and possible trauma responses that are masquerading as ADHD.

DIAGNOSES

• ADHD, combined presentation (provisional)

- Provisional means “for now”

• Unspecified Trauma - and Stressor-Related Disorder

- This diagnosis is provided when there is enough information to suggest a trauma response but a full diagnosis is unable to be made with that information.  

- This client had a traumatic experience that doesn’t fall under the abuse category but is creating emotional reactions and difficulties such that a diagnosis is needed to address these reactions

• Other Specified Anxiety Disorder (secondary to ADHD)

- This means that symptoms do not qualify as a general anxiety or major depressive episode and are instead caused or influenced by difficulties created within the primary diagnoses.  For example, “I’m anxious/sad because I can’t focus.”

• Rule out Autism Spectrum Disorder due to mild social sensitivity, difficulty with changes in routine and making eye contact, and sensory concerns

WHAT ARE THE CLIENT’S STRENGTHS?

With some students, their strengths are that they are functioning adequately in some areas and this helps offset vulnerabilities in other areas. In this client’s case, she has very well developed verbal abilities.  She uses and understands language well and is able to express herself and her thoughts adequately.  Her reasoning skills and working memory ranged from the Average to Superior range of ability, indicating that she can incorporate previously learned knowledge into problem solving strategies and remember information well.  Client also has very good reading skills and her math skills are developing well.

WHAT ARE THE CLIENT’S VULNERABILITIES?

• Processing Speed

Client’s ability to process information quickly was an area of improvement for her.  She may have difficulty working with speed and efficiency.  This may cause problems understanding lengthy instructions or lectures and completing tasks and tests in a timely fashion and under timed conditions.

• Executive Functioning and Attention

Client may struggle with response time, response consistency, and sustained attention.  In addition to trouble paying attention, she may respond to things quickly in one context while responding slowly in another and her pattern of responding may vary based on task and context as well.  Rating forms indicated high levels of disorganization, trouble focusing, managing frustration, remembering things, and monitoring behavior and task completion.  All of these areas affect her ability to problem solve, complete tasks to her ability level and expectations, manage her frustrations about her lack of ability, and do all of these things within a set time limit.  She may require more check-ins and more time and instruction to get things done.

• Social/Emotional Functioning

There were no elevations related to PTSD on any self or parent rating forms.  However, parent endorsements showed high levels of aggression, anxiety, depression, and atypical behaviors along with trouble adapting to change, showing leadership skills, taking care of daily living activities, communication, controlling anger and emotions, responding negatively to changes, and being resilient.  

Overall, the client’s emotion regulation skills are largely impacted by executive dysfunction, which influences other areas of functioning as well.  She may struggle to take initiative and when she cannot, become angry, irritable, anxious, and/or sad and this causes her to react aggressively.  Though her verbal skills are good, she may still have trouble finding the words to express her inner emotional experience and what is bothering her.

HOW CAN THE CLIENT BEST BE SUPPORTED?

For client’s where their vulnerabilities outweigh their strength and well-developing areas, it is important to take a strength-based approach to treatment that helps them highlight and feel good about what they are good at while also realistically talking about where he continues to struggle.  Ways to do that include:

• Counseling, specifically cognitive behavioral therapy, to address attention concerns and emotional disturbance.  Counseling should also allow the space and opportunity to process and work through her traumatic experience and resulting emotional difficulties.
• Family counseling to address previous harmful interaction
• Medication consultation for ADHD and mood alterations
• Home environment changes including support, structure, routine, and firm boundaries for positive and negative behaviors
• Academic accommodations including:

- Extended time and private testing space

- Extended deadlines for assignments and substitution assignments

- Frequent breaks

- Simplified instructions

• Occupational therapy for sensory concerns
• Re-evaluation in 1 year

ADULT  FOCUSED EVALUATIONS

ADHD - FEMALE

REFERRAL INFORMATION

Client is a 42 year old white female referred for ADHD due to issues with attention, getting started on and completing tasks, finishing chores, prioritizing work, and time management.  She also has trouble with remembering appointments and obligations, making careless mistakes, concentrating on what others are saying, staying organized, talkativeness, and interrupting others.

Client had issues with language as a child and received speech therapy until age 8.  She has positive familial and marital relationships.  Her family moved from another state and there were still things in boxes.  Client reported having limited free time because she is often catching up on work during evenings and weekends and has trouble following up with her social network.

Client initially enrolled in college as a music major before failing out of her program due to issues with execution, distractibility, and focus.  She re-enrolled after several years and majored in four combined science areas, which she was able to successfully maintain and graduate.  However, in order to maintain grades, the client often struggled with re-reading paragraphs for hours, working hard daily to keep up with studies outside of class, spending evenings and weekends completing homework, sitting in the front row of lectures to eliminate distractions and improve focus, and being distracted during exams if there was noise.  Client also completed a professional master’s degree program that was more application-based learning.  However, she still struggled with sitting and reading for courses.  She completed a second master’s degree program but was delayed in finishing her thesis due to focusing issues, trouble reading research materials, and getting started on tasks.

Client is employed full time and in a leadership role.  She reported struggles with focus and getting distracted during meetings, needing longer periods of time to read reports, missing important details in meetings, working late and needing extra time to meet deadlines, and occasionally requesting extensions.  While she has not been officially reprimanded for her difficulties, there have occasionally been strained working relationships as a result.

Client is generally healthy but struggles with sleep due to racing thoughts about incomplete tasks.  She has no history of counseling or medications.  She struggles with depression, anxiety, and increased stress related to task completion and consumes 200mg of caffeine daily in coffee and occasional energy drinks.  During testing, there were no outward signs of inattention or hyperactivity but sometimes required repetition of test instructions or questions.  She arrived on time to her appointment.

DIAGNOSES

When making or ruling an ADHD diagnosis, available information must indicate the presence of symptoms during childhood (prior to age 12), in more than one environment, as well as clinical impairment.  Otherwise a diagnosis cannot be made.  For adults, it sometimes requires a more thorough clinical interview and asking questions about things beyond the criteria such as “what was completing homework like?” “How did you turn in your homework?” and “What is driving like for you?”  Through this, we can determine how impairment is manifesting and what symptoms may have presented differently in childhood.  We must also determine and rule out whether attention deficit and/or executive dysfunction is being caused or influenced by emotional difficulties.

• ADHD, combined presentation
• Other Specified Anxiety and Depressive Disorders

- This means that symptoms do not qualify as a general anxiety or major depressive episode and are instead caused or influenced by difficulties created within the primary diagnoses.  For example, “I’m anxious/sad because I can’t focus.”

WHAT ARE THE CLIENT’S STRENGTHS?

• Nonverbal Skills

Client has significant strengths in nonverbal skills, which indicates the ability to reason through available information to improve problems solving and to process visual information.  

• Verbal Skills & Processing Speed

Her verbal skills and processing speed are developing well, showing no issues with understanding and using language or processing information quickly and efficiently.

• Academic Skills

Academically, the client’s reading, spelling, and math skills were developing nicely, and she showed a high ability to comprehend what she was reading.

In cases where reading comprehension is high but clients are struggling to remember what they read in daily life, this points to an executive functioning deficit and/or emotional difficulties that may impact reading ability.

WHAT ARE THE CLIENT’S VULNERABILITIES?

• Memory

Client showed deficits in immediate and contextual visual memory with improvements after delay and when provided recognition cues.  This means that when it comes to remembering visual details in the context of a scene, she struggled to recount what had been changed or moved.  Consider if someone forgot their keys and could not remember where they were.  Deficits in this area may affect her ability to scan a room, note what was already there or may have been out of place, and use that information to help her locate missing keys.

This type of memory improved after she had some time for it to process and sink in and improved even more when she was given memory cues (i.e., visuals to jog her memory).

• Executive Functioning

Client showed difficulty with rapid retrieval and verbal switching and flexibility.  This means she has trouble accessing information from memory quickly and unconsciously shifts attention between one verbal task and another.  This may affect thinking, memory, and following conversations and lectures.

• Attention

Client showed impairments in visual and auditory response control and processing.  This means that she may have faster or slower processing and reactions to things she sees and/or hears in different contexts or situations.  She also struggles with general and sustained auditory and visual attention.  Overall, this indicates that the client is more likely to tune things out unless she is actively engaged and struggle to get back on track when her attention is distracted.  She performs somewhat better with visual attention when there is a higher need for her to perform and pay attention to visuals.

Several inattentive and hyperactive/impulsive symptoms were reported currently and in childhood by client and observer ratings.

• Social/Emotional Functioning

The client is emotionally struggling with bodily preoccupations that create anxiety, periods of unconstrained energy, restlessness, low frustration tolerance, irritability, and moodiness.  Other difficulties with self-confidence, feelings of inadequacy, and fears of separation and disapproval were also rated.  These difficulties may further impact overall processing and speed, attention, and memory.

• Adaptive Functioning

Adaptive functioning refers to those skills that are necessary for us to effectively navigate through the demands that are placed on us by our environments and others.  These types of skills include communicating with others, independence, expressing yourself, hygiene, and completing other home-based tasks to name a few.  This client showed low adaptive abilities in most areas including academics, recreational activities, basic home care and living, self-direction, social skills, and work life.  This means that she is struggling to maintain adequate functioning and navigate her social and work life, perform tasks without help, keep a clean and tidy home or satisfying home life, and find and enjoy leisure activities.

HOW CAN THE CLIENT BEST BE SUPPORTED?

For high functioning clients who may have several vulnerabilities, it can often be a blow to their self-esteem and self-concepts.  It is important to take a strength-based approach to treatment that helps them highlight and feel good about what they are good at while, what they have been able to accomplish thus far, and how well they are currently maintaining while also realistically talking about where she continues to struggle.  Ways to do that include:

• Counseling, specifically cognitive behavioral therapy, to address attention concerns and emotional disturbance.  Counseling may also focus on exploring and processing how current difficulties are impacting self-esteem and self-concept.
• Medication consultation for ADHD
• Workplace accommodations including but not limited to reminders, immediate feedback, assistance with extensive reading materials, materials ahead of meetings, a personal assistant, additional time to finish projects, spelling and grammar checking software, and dictation options.
• Books and online resources for ADHD

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ADHD - MALE

REFERRAL INFORMATION

Client is a 31 year old male referred for ADHD due to difficulties with executive functioning that affect task completion and work completion.  He struggles with executive dysfunction under high stress, during busy times of year, or when given more responsibility.  He also has trouble remembering “basic things” like turning off the car and locking the doors at home.

Client has good familial and marital relationships and adequate social supports and networks.  However, he struggles helping his wife manage daily responsibilities such as scheduling appointments or completing important paperwork.  He graduated with a bachelor’s degree and working on a financial certification.  Client historically excelled in school and had strong interpersonal skills and teacher relationships that helped him avoid reprimands from failing exams and submitting late work.   He often had trouble meeting deadlines, staying organized, and procrastinating.  He frequently required extensions for class assignments and required the pressure and panic of deadlines to help him complete work.  Client once stayed awake for 48 hours to finish a research paper and turned it in within 10 minutes of the deadline, later receiving an award for his work.  He was homeschooled until high school and was one grade ahead of his peers.  However, due to difficulty with procrastination and work completion, he fell one grade behind so that he was enrolled in the correct grade for his age.

Client maintains full time employed with variable work performance, sometimes receiving praise for his good work one week and threats of termination the following week.  He struggles with time management, following through on projects and paperwork, making careless mistakes on documentation, organizing things to delegate to others, and having a disorganized work space.  He wakes up early often to complete work and has difficulty getting started.

Client is generally healthy with occasional insomnia.  He participates in counseling to manage his difficulties.  He frequently starts projects that go unfinished and struggles with distractibility, multi-tasking, and fidgeting.  Several of his difficulties with attention and executive functioning have been present since childhood.  Client also consumes 2-3 cups of caffeine daily.  Behaviorally, he arrived on time to his appointment.  He occasionally required repetition of test instructions or questions, exhibited mild fidgetiness, completed tasks quickly, began before instructions, blurted out answers, and occasionally worked over time constraints.

DIAGNOSES

When making or ruling an ADHD diagnosis, available information must indicate the presence of symptoms during childhood (prior to age 12), in more than one environment, as well as clinical impairment.  Otherwise a diagnosis cannot be made.  For adults, it sometimes requires a more thorough clinical interview and asking questions about things beyond the criteria such as “what was completing homework like?” “How did you turn in your homework?” and “What is driving like for you?”  Through this, we can determine how impairment is manifesting and what symptoms may have presented differently in childhood. We must also determine and rule out whether attention deficit and/or executive dysfunction is being caused or influenced by emotional difficulties.

The following diagnoses were provided:

• ADHD combined presentation
• Other Specified Anxiety and Depressive Disorders

- This means that symptoms do not qualify as a general anxiety or major depressive episode and are instead caused or influenced by difficulties created within the primary diagnoses.  For example, “I’m anxious/sad because I can’t focus.”

WHAT ARE THE CLIENT’S STRENGTHS?

• Compensatory Strategies

Often high achieving adults who are also very intelligent create systems to manage the areas where they struggle.  In this case, the client used their strong interpersonal skills to navigate reprimands throughout school and their intelligence to compensate for several difficulties.  Many people do this to some degree but with this client, that was one of his biggest strengths.

• Verbal Skills

Client showed very well developed verbal skills with a strength for vocabulary. He is able to use and understand language well and is able to express himself and his thoughts adequately.

• Other Cognitive Skills

Client’s nonverbal skills and working memory are developing nicely.  He has no difficulty using nonverbal reasoning and problem solving or remembering information for immediate use or after a delay.

• Academic Abilities

Client showed adequate comprehension and spelling abilities and well developed reading and math skills.  This rules these out as sources for ongoing executive dysfunction.

WHAT ARE THE CLIENT’S VULNERABILITIES?

• Attention and Executive Functioning

Client mild deficits in visual memory when provided memory cues, suggesting a preference toward free recall rather than multiple choice memory.  His attention and concentration scores were typically compromised with deficits in verbal memory for sequencing information.  This impacts remembering the order for verbal information such as steps to complete a task and/or what may need to be done first.  There was evidence of trouble with cognitive flexibility, auditory and visual response control and general and sustained attention.  This means that he may have faster or slower processing and reactions to things he sees and/or hears in different contexts or situations and struggle with switching between thinking about multiple concepts.

Moderate symptoms are currently present, which was corroborated by observer reports, and were also present during childhood.

• Social/Emotional Functioning

Client may conceal negative reactions to stress and problematic relationships.  While this is not inherently a bad thing, it can be impairing and sometimes damaging when there is little acknowledgement of the problem or outlets for the stress and emotions associated with the problem.

Being viewed as troubled or vulnerable causes this client distress.  He may attempt to engage others socially to avoid feeling tension.  He is easily excited and often intolerant of frustration, delay, or disappointment.  He shows impulsive behaviors and an unrealistically optimistic attitude that may contribute to additional emotional disturbance.  He may only acknowledge his shortcomings when there are no other options, experiencing mood shifts as a result.

Emotional difficulties often have an additional impact on executive functioning, memory, attention, and processing information.  When considering how this client conceals his emotions, that may lead to increased stress responses that create a cycle for how he handles things.

• Adaptive Functioning

Adaptive functioning refers to those skills that are necessary for us to effectively navigate through the demands that are placed on us by our environments and others.  These types of skills include communicating with others, independence, expressing yourself, hygiene, and completing other home-based tasks to name a few.  This client struggles with completing chores and work activities adequately, navigating community activities, maintaining a positive marital relationship, managing money, driving, and overall daily responsibilities.

HOW CAN THE CLIENT BEST BE SUPPORTED?

For high functioning clients who may have several vulnerabilities, it can often be a blow to their self-esteem and self-concepts.  It is important to take a strength-based approach to treatment that helps them highlight and feel good about what they are good at while, what they have been able to accomplish thus far, and how well they are currently maintaining while also realistically talking about where she continues to struggle.  Ways to do that include:

• Counseling, specifically cognitive behavioral therapy, to address attention concerns and emotional disturbance.  Counseling may also focus on exploring and processing how current difficulties are impacting self-esteem and self-concept.
• Medication consultation for ADHD
• Workplace accommodations including but not limited to reminders, materials ahead of meetings or presentation, time management strategies, dictation options, extra time to finish projects, using spelling and grammar software, and asking for summaries or notes and meetings.
• Books and online resources for ADHD
• Academic accommodations if needed including extended time, distraction free testing environment, and frequent breaks.