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Rating scales are an essential part of the full assessment process for attention-deficit hyperactivity disorder (ADHD).1-4 Rating scales vary in format and scope, recognising the need for multidisciplinary input on a patient’s condition and symptomatology, as addressed in guidelines for ADHD.1-4 For any specific requirement, particular rating scales will have associated strengths and limitations.

Do you think there is sufficient access to information and the tools required to accurately and reliably diagnose patients with ADHD?

Key variable components of ADHD rating scales include:

  • Specificity – ADHD-specific scales that rate symptoms include the ADHD Rating Scale V (ADHD-RS-V)5 for children and the Adult ADHD Self-Report Scale for adults.6 Standardised rating scales enable clinicians to evaluate multiple aspects of well-being and compare these results with specific clinical subgroups, the general population, or both.
  • Assessment measures – include:7
    • Frequency or severity of ADHD symptoms
    • Levels of functional impairment
    • Impact on quality of life and finances.
  • Patient population­ – rating scales are available for use in children, adolescents or adults.7
  • Means of administration ­– clinician-, parent-, teacher- or self-reporting rating scales have been developed; teachers in particular are recognised to have a crucial role in assisting with accurate clinical case identification in children with ADHD.7
  • Scoring method – questions may require Likert scale, yes/no, or free-text responses. Cut-off values for improvement following treatment vary between rating scales.7
  • Availability and cost – many ADHD rating scales are freely available to clinicians; however, some require online purchase. Copyright restrictions vary between rating scales and must be adhered to.7

Rating scale selection

Rating scale selection depends on the requirements of the investigator. Some rating scales (e.g. the Diagnostic Interview for ADHD in Adults8) are designed only for diagnosis, whereas others are optimised to measure symptom frequency (e.g. Swanson, Nolan and Pelham [SNAP]-IV9), symptom severity (e.g. ADHD-RS-V5) or improvement in symptoms over time (e.g. Clinical Global Impression of Improvement10). Treatment responses are best measured by rating scales with well-defined minimal clinically important difference, such as the ADHD Investigator Symptom Rating Scale.11

Interactive module: rating scale toolkit

Rating scales used for the assessment of ADHD prior to formal diagnosis

Having viewed the interactive module above, do you think that you will use different rating scales in the future to accurately and reliably diagnose patients?

Rating scales are only one component of a comprehensive assessment process, and the National Institute for Health and Care Excellence (NICE) guidelines recommend that the diagnosis should be made on the basis of:

  • A full clinical and psychosocial assessment of the individual, which should include discussion about behaviour and symptoms in the different domains and settings of the individual’s everyday life and
  • A full developmental and psychiatric history and
  • Observer reports and assessment of the individual’s mental state.1

A diagnosis of ADHD should not be made solely on the basis of rating-scale or observational data.1  However, rating scales and observations are valuable adjuncts, and observations are useful when there is doubt about symptoms.1

  1. NICE guideline 2018. Attention deficit hyperactivity disorder: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng87. Accessed February 2019.
  2. Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines. Fourth Edition. Toronto, ON; CADDRA, 2018.
  3. Banaschewski T, Hohmann S, Millenet S. Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) im Kindes-, Jugend- und Erwachsenenalter. DGKJP, DGPPN and DGSPJ German guidelines. 2018.
  4. Guías de Práctica Clínica en el SNS. Grupo de trabajo de la Guía de Práctica Clínica sobre las Intervenciones Terapéuticas en el Trastorno por Déficit de Atención con Hiperactividad (TDAH). 2017.
  5. DuPaul GJ, Power TJ, Anastopoulos AD, et al. ADHD Rating Scale-5 for Children and Adolescents: Checklists, Norms, and Clinical Interpretation. New York, NY; Guilford Press, 2016.
  6. Ustun B, Adler LA, Rudin C, et al. The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5. JAMA Psychiatry 2017; 74: 520-526.
  7. Kollins SH, Sparrow EP. Rating scales for the assessment of ADHD. In: Conners CK, ed. Guide to Assessment Scales in Attention-Deficit/Hyperactivity Disorder. Chester, UK: Springer Healthcare Communications Ltd., 2010, p6-40.
  8. Kooij JJS, Francken MH. Diagnostic Interview for ADHD in Adults (DIVA). 2010. Available at: http://www.divacenter.eu/Content/VertalingPDFs/DIVA_2_EN_FORM%20-%20invulbaar.pdf. Accessed February 2019.
  9. Swanson JM. The SNAP-IV Teacher and Parent Rating Scale. 2013. Available at: https://www.crfht.ca/files/8913/7597/8069/SNAPIV_000.pdf. Accessed February 2019.
  10. Guy W, National Institute of Mental Health (U.S.). Psychopharmacology Research Branch. Clinical Global Impressions. In: Guy W, ed. ECDEU Assessment Manual for Psychopharmacology, Revised. Rockville, MD: US Dept Health, Education and Welfare, 1976, p217-222.
  11. Spencer TJ, Adler LA, Meihua Q, et al. Validation of the Adult ADHD Investigator Symptom Rating Scale (AISRS). J Atten Disord 2010; 14: 57-68.
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