Rating Scales

Rating scales are a useful tool for assessing whether a patient meets the DSM-IV criteria necessary for a diagnosis of adult ADHD. They can also be useful in assessing current symptoms.

Current Symptom Surveys

Approximately 60% of children with ADHD continue to experience the disorder through adulthood,^[1] and the hyperactive, restless symptoms of a child with ADHD can manifest as feelings of internalized restlessness for an adult.^[5] Current symptom surveys can be divided into clinician-administered and self-report forms. Because symptoms like internalized restlessness, feeling disorganized, and being easily distracted are not always apparent to observers, self-report scales are an effective way to capture the symptoms of adults with the disorder.^[6]

ADHD Rating Scale

The ADHD Rating Scale is an 18-item scale that rates symptoms using a 4-point Likert-type severity scale (0 = none, 1 = mild, 2 = moderate, and 3 = severe). It is based on the DSM-IV criteria for ADHD. It has 9 items that assess inattentive symptoms and 9 items that assess hyperactive and impulsive symptoms. Sample rating questions include, "Avoids tasks (eg, schoolwork, homework) that require sustained mental effort" and "Talks excessively." The ADHS Rating Scale has been developed and standardized as a rating scale for children. Although clinician-raters can be trained to successfully administer this scale to adults, they require a period of standardization and training. The scale queries domains of symptoms without a contextual basis and therefore has less utility as a self-administered scale. The ADHD Rating Scale is available through Guilford Press.

Copeland Symptom Checklist

The Copeland Symptom Checklist for Attention Deficit Disorders--Adult Version is designed to help assess whether an adult has characteristic ADHD symptoms, to what degree, and which areas of functioning are most seriously affected. The checklist covers 8 areas, including inattention/distractibility, impulsivity, activity level problems, noncompliance, underachievement/disorganization/learning problems, emotional difficulties, poor peer relations, and impaired family relationships. This scale, which may be used less often than some of the others reviewed here, is available from Resurgens Press.

The Brown ADD Scale

The Brown ADD Scale is a frequency scale with 40 items. To descriptions like "'spaces out' involuntarily and frequently when doing required reading; keeps thinking of things that have nothing to do with what is being read," "is excessively forgetful about what has been said, done, or heard in the past 24 hours," and "is easily frustrated and excessively impatient," patients answer whether the symptoms occur "0 = never," "1 = once a week or less," "2 = twice a week," or "3 = almost daily." Like the Wender-Reimherr Scale and Conners scale (described below), the Brown ADD Scale explores the executive functioning aspects of cognition that are associated with ADHD. This assessment, which has standardized, validated, clinician-rated, and self-report forms, can be ordered from The Psychological Corporation.

The Wender-Reimherr Adult Attention Deficit Disorder Scale

The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADS) is intended to measure the severity of the target symptoms of adults with ADHD using the Utah Criteria, which Wender developed.^[7,8] It measures symptoms in 7 categories: attention difficulties, hyperactivity/restlessness, temper, affective lability, emotional overreactivity, disorganization, and impulsivity. The scale rates individual items from 0 to 2 (0 = not present, 1 = mild, 2 = clearly present) and summarizes each of the 7 categories on a 0-to-4 scale (0 = none, 1 = mild, 2 = moderate, 3 = quite a bit, 4 = very much). An example of a question in the temper section is, "Does your temper cause problems for you? Do you lose control during temper outbursts? (saying things you regret, becoming aggressive, acting in a threatening manner, or behaving impulsively)." A question in the affective lability section is, "Does your mood change frequently, going up and down like a roller coaster in the sense of getting sad or feeling 'up'?" The WRAADS may be particularly useful in assessing the mood lability symptoms of ADHD. In fact, a recent study has shown that the WRAADS effectively measured improvement in symptoms in mood dysregulation in a large, controlled trial of the norepinephrine reuptake inhibitor, atomoxetine.^[9]*

The screening version of the Conners' Adult ADHD Rating Scale (CAARS) is a 30-item frequency scale with items like "loses things necessary for tasks or activities" and "appears restless inside even when sitting still." Symptoms are assessed with a combination of frequency and severity. Patients respond on a 4-point Likert-type scale (0 = not at all, never; 1= just a little, once in a while; 2 = pretty much, often; and 3 = very much, very frequently). All 18 items from the DSM-IV can be extrapolated from the CAARS. There are also observer and self-report versions of the CAARS. The scale has been validated for both the clinician-administered and self-rated versions. The CAARS is available through Multi Health Systems, Inc.

The Adult Self-Report Scale

The Adult Self-Report Scale (ASRS) is an 18-item scale that can be used as an initial self-screening tool to identify adults who might have ADHD. It was developed by the Workgroup on Adult ADHD, comprising Lenard Adler, MD, of New York University Medical Center, Ron Kessler, PhD, of Harvard Medical School, and Thomas Spencer, MD, of Harvard Medical School and Massachusetts General Hospital. Symptoms are rated on a frequency basis: 0 = never, 1 = rarely, 2 = sometimes, 3 = often, and 4 = very often. The ASRS modifies the language of the ADHD-RS in several ways. In the ASRS, a contextual basis for adult symptoms is provided. So, instead of an item on the ADHD-RS like "difficulty waiting," the corresponding item on the ASRS is "difficulty waiting your turn in situations when turn-taking is required." Additionally, the ASRS breaks down each symptom into its own question, whereas the ADHD-RS sometimes queries 2 symptoms in a single question. For example, an item on the ADHD-RS reads, "Failure to pay close attention to details. Making careless mistakes," and the ASRS queries simply, "Making careless mistakes." The ASRS is now available through the World Health Organization (WHO).

Patients can complete the scale in approximately 5 minutes, responding to items like "How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?" and "How often do you have difficulty unwinding and relaxing when you have time to yourself? Nine items assess inattention, and 9 items assess hyperactivity/impulsivity. Once the patient has completed the scale, it can be scored quickly and used as a starting point to discuss the details of a patient's clinical history in greater depth.

The ASRS can serve several purposes for patients who are believed to have ADHD. It can assess the likelihood of a diagnosis and is useful as a diagnostic aid after an initial screening to further assess symptoms and to evaluate impairments. The questionnaire's content reflects the importance that the DSM-IV places on symptoms, impairments, and history for a correct diagnosis. Scoring guidelines are based upon the total score in either the inattentive and hyperactive/impulsive subsets (using the higher score of either), which yields a diagnostic likelihood of the patient having ADHD. The scale's scoring produces a result that describes the patient as being unlikely, likely, or highly likely to have ADHD. The scale has been validated using the National Comorbidity Survey cohort as well as in well-characterized adult ADHD populations.^[10]

In the National Comorbidity Survey, adult ADHD patients, with variable symptom severity who were being evaluated or treated in New York University and Massachusetts General Hospital Adult ADHD Programs, were evaluated first with the ASRS and then by standard clinician administration of the ADHD-RS. Internal consistency of symptom scores on each scale was assessed by Cronbach's alpha. Agreement of raters was established by intraclass correlation coefficients (ICCs) between scales. Internal consistency was high for both patient- and rater-administered versions. The ICC between scales for total scores and for inattentive and hyperactive-impulsive symptoms were also high. There was also substantial agreement for individual items and significant kappa coefficients for all items (P < .001).^[2]

The scale is available through the NYU Medical Web site, through The WHO, and available for download from Medscape Psychiatry after completion of this clinical update.

*The WRAADS is available by contacting Fred W. Reimherr, MD, Mood Disorders Clinic, Department of Psychiatry, University of Utah Health Science Center, Salt Lake City, UT 84132.