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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.

Key variable components of ADHD rating scales include:

  • Specificity – ADHD-specific scales that rate symptoms include the ADHD Rating Scale IV (ADHD-RS-IV) for children5 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
  • 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 ADHD1-3
  • Scoring method – questions may require Likert scale, yes/no, or free-text responses. Cut-off values for improvement following treatment vary between rating scales
  • 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.

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-IV 269), symptom severity (e.g. ADHD-RS-IV5) 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.

Interactive module: rating scale toolkit

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

Rating scales are only one component of a comprehensive assessment process,1-4 and the National Institute for Health and Care Excellence (NICE) guidelines recommend that the diagnosis should only be made after a full clinical and psychosocial evaluation, and never on the basis of rating-scale data alone.1 This is because rating scales have less sensitivity and specificity for diagnosis compared with a full diagnostic assessment, and they can be subject to inter-rater variability.1 Many rating scales describe symptoms only, with no consideration given to the level of impairment or developmental appropriateness.1

  1. National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis and management. Available at: https://www.nice.org.uk/guidance/cg72/resources/attention-deficit-hyperactivity-disorder-diagnosis-and-management-975625063621. Last updated 2016. Accessed 05 January 2017.
  2. Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder — first upgrade. Eur Child Adolesc Psychiatry 2004; 13(Suppl 1): I/7-I/30.
  3. Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines. Toronto: CADDRA, 2011.
  4. Kooij SJJ, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry 2010; 10: 67.
  5. DuPaul GJ, Power TJ, Anastopoulos AD, et al. ADHD Rating Scale IV: Checklists, norms, and clinical interpretation. New York: Guilford 1998.
  6. Adult ADHD Self-Report Scale (ASRS) Checklist. Available at: http://webdoc.nyumc.org/nyumc_d6/files/psych_adhd_checklist.pdf. Last updated 2016. Accessed 05 January 2017.
  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. Springer Healthcare Ltd., 2010: 6-40.
  8. Kooij JJ, Francken M.H. Diagnostic Interview for ADHD in Adults (DIVA). Available at: http://www.divacenter.eu/Content/VertalingPDFs/DIVA_2_EN_FORM%20-%20invulbaar.pdf. Last updated 2010. Accessed 05 January 2017.
  9. Swanson JM. The SNAP-IV Teacher and Parent Rating Scale. Available at: http://www.tn.gov/assets/entities/behavioral-health/attachments/Pages_from_CY_BPGs_454-463.pdf. Last updated 25 February 2013. Accessed 04 January 2017.
  10. Guy W. Clinical Global Impressions in: ECDEU Assessment Manual for Psychopharmacology, revised. Rockville, MD: US Dept Health, Education and Welfare, 1976: 217-222.
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