ADHD Weekly 2017-02-09

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Primary care physicians faced with diagnosing and treating patients with ADHD must make informed decisions about the most effective and relevant assessment and monitoring tools for their patients. ADHD rating scales are important tools to use as part of a comprehensive diagnosis and treatment of ADHD in both children and adults. The American Academy of Pediatrics’ practice guidelines recommend that clinicians use rating scales in assessing ADHD:

1. for the initial diagnosis of a child with ADHD
2. in the assessment for co-occurring conditions
3. for monitoring the treatment strategy that has been put in place

There is an abundance of rating scales that have been developed by ADHD experts and organizations, including the National Institute for Children’s Health Quality (NICHQ) and the World Health Organization. Some focus on ADHD-specific symptoms, others assess a variety of behavioral symptoms. Some are brief, with only a 10-item questionnaire, while some ask more than 100 questions. There are those freely available online while others must be purchased. To assist practitioners in selecting scales for use in their practices, we will discuss what rating scales measure, the different types of scales, and highlight some well-known psychometrically validated scales that are commonly used.

Rating scales may be completed by an adult, a child, parent, other family members, teachers, and/or the clinician or other professional observer to help determine which ADHD symptoms and co-occurring conditions are present in the patient, in which environments (home, school, work, social), and over what time period. Scales may also detect the levels of impairments that exist due to the ADHD symptoms.

ADHD-specific scales (or narrowband scales) are designed to focus on ADHD symptoms (inattentive, hyperactive-impulsive) and can determine the presence of core symptoms of ADHD as defined by the Diagnostic and Statistical Manual (DSM-5) criteria for ADHD. Examples of narrowband ADHD-specific rating scales for children include:

• Vanderbilt scales
• Conners scales
• ADHD Rating Scales (ADHD-RS-V)
• Swanson, Nolan and Pelham (SNAP) scale

Scales for adults include:

• Adult ADHD Self-Report Scale Symptom Checklist Version 1.1 (Adult ASRS)
• Conners Adult ADHD Rating Scales (CAARS)
• Wender Utah Rating Scale

Broadband rating scales assess a variety of behavioral conditions in addition to the core symptoms of ADHD, such as functional impairments in peer relationships and academics, executive function deficits in organization and time management, and co-occurring conditions such as anxiety, depression or oppositional/conduct problems. Examples of broadband scales are:

• Child Behavior Checklist (CBCL)
• Behavior Assessment Scale for Children (BASC)
• Brown Attention Deficit Disorder Scales (BADDS)

One popular rating scale that can assess a child or adult’s functional problems with family, school/work, life, self-concept, social skills, and risk taking is the Weiss Functional Impairment Rating Scale. The data can be interpreted as a measure of the patient’s quality of life.  The scale has been validated by multiple studies and translated into 18 languages.

The Agency for Healthcare Research and Quality (AHRQ) has noted narrowband scales are more accurate than broadband scales for distinguishing children affected by ADHD from those not affected by ADHD. A recent study published in Pediatrics compared these popular scales—the Child Behavior Checklist-Attention Problem (CBL-AP), the Conners Rating Scale-revised (CRS-R), and the Conners Abbreviated Symptom Questionnaire (ASQ)—for their assessment performance. The researchers found the ASQ is easiest to use and has high accuracy for assessing ADHD, but to detect co-occurring conditions, they recommend the CBCL because it can be used together with other CBCL subscales.

To use rating scales well, practitioners are encouraged to take training courses in the diagnosis and treatment of ADHD. There are free courses online such as Medscape’s Determining the Best Test in ADHD Diagnostic Scales. The American Professional Society of ADHD and Related Disorders (APSARD) also provides free CME online courses on adult ADHD diagnosis and treatment, including using selected rating scales. Low-cost online courses are also available, such as Dr. Russell Barkley’s ADHD in Children: Diagnosis and Assessment.

For additional information:

• A list of well-known ADHD rating scales can be found on the CHADD’s National Resource Center on ADHD website.
• DefiniPoint provides information and access to selected rating scales online to make it easier for practitioners seeking assessment tools. The site also provides access to the Weiss ADHD Comorbid Screen, which is not a rating scale but a screening tool for co-occurring conditions in children and adults to detect conditions that may have been missed by the clinical interview or rating scale data.
• The ADHD Institute has an interactive module that provides an overview of many rating scales used in the assessment of patients with ADHD.
• The National Association for Continuing Education (NACE) provides a free adult ADHD assessment toolkit online that contains several rating scales for screening symptoms, detecting functional impairments and co-occurring conditions, and monitoring treatment response.
• The Canadian ADHD Resource Alliance (CADDRA) also provides a free ADHD Assessment Toolkit online that contains several assessment and follow-up forms for children and adults, including rating scales to screen symptoms and functional impairments.

References:

• Brooks, Megan. ADHD Diagnostic Scales: Which Test is Best? Medscape, March 2, 2016.
• Langberg, Joshua et al. (2008). Assessing children with ADHD in primary care settings. Expert Review of Neurotherapeutics, v8 n4, pp. 627-641.
• Surman, Craig B.H. (2013). Chapter 2: Clinical Assessment of ADHD in Adults in ADHD. In C. Surman (Ed.). Adults: A Practical Guide to Evaluation and Management. (pp. 19-44). New York, NY: Springer.

Do you have a preferred rating scale you use in your practice? Discuss with our community.