Adult ADHD Screening
Upon completion of this course, participants will be able to:
- Review our current screening tools for ADHD.
- Evaluate ADHD in adults.
- Discuss comorbidity in the diagnosis of ADHD.
Some patients have clear-cut ADHD: easily distracted, difficulty
staying seated, constantly losing things and forgetting appointments,
problems that date back to childhood, and significant impairment in
multiple areas of their life. Diagnosing a patient with those symptoms
would probably seem easy, but screening for adult ADHD often isn't this
textbook simple. Since almost anyone who walks into the office could
fall somewhere on a continuum from mild problems with disorganization to
severe ADHD, how can one confidently know where the cut-off points lie?
Screening tools like rating scales, which are typically modeled on
the diagnostic criteria of the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV), are a necessary and
important first step to making a diagnosis, particularly for a primary
care physician or a psychiatrist whose specialty is not adult ADHD. Most
primary care physicians and psychiatrists have not had training in this
area. About 60% of children with ADHD have symptoms that persist into
adulthood, which translates into 4% of the US adult
population, or 8 million adults. There are 3 main types of rating
scales: self-report, significant other/observer report, and
clinician-administered. The Adult Self-Report Scale (ASRS) is a newly
developed self-rating scale that can be used to screen patients who
might have ADHD. There are also several other widely used
DSM-IV Criteria for the Diagnosis
Familiarity with the diagnostic criteria for ADHD is extremely
important. Most of the major rating scales used for screening patients
are modeled on the criteria laid out in the DSM-IV. There
are 3 critical aspects of the diagnosis: (1) at least 6 of 9 symptoms
for one of the ADHD subtypes, (2) childhood onset of symptoms, and (3)
impairment in at least 2 areas like work/school, home, and social
According to the DSM-IV, ADHD can be divided into 3 subtypes:
predominantly inattentive; predominantly hyperactive-impulsive; and the
combined type, for which a patient must fully meet the criteria for both
of the other 2 subtypes. Inattentive symptoms include failure to pay
close attention to detail, difficulty sustaining attention, not
listening when spoken to, failure to follow through on instructions or
finish tasks, difficulty organizing, reluctance to engage in activities
that require sustained mental effort, often losing things, being easily
distracted, and often being forgetful. A patient must have at least 6 of
these 9 symptoms to be considered to have the inattentive subtype.
The symptoms of the hyperactive-impulsive subtype include frequent
fidgeting; frequently leaving one's seat in situations where staying
seated is expected; running about, climbing excessively, or a feeling of
internal restlessness; difficulty engaging quietly in leisure activities
; often "on-the-go" or acting like one is "driven by a
motor"; talking excessively; blurting out answers; having
difficulty waiting one's turn; and interrupting or intruding on others.
Again, at least 6 of these symptoms must be present for diagnosis of the
hyperactive-impulse subtype. Patients who meet all criteria for both the
inattentive and hyperactive-impulsive subtypes are diagnosed with the
The symptoms that patients describe cannot be episodic -- they must
persist for 6 months or longer and must affect at least 2 areas of
functioning (ie, school, work, home, social life). Age of onset is also
an important adult ADHD diagnostic criterion. Symptoms must date back to
age 7 or younger. If the childhood history is not present, the patient
does not meet criteria for a diagnosis. Ways of documenting childhood
history include the ADHD module from the Kiddie-SADS and the Connors,
Barkley, and Brown diagnostic symptoms scales (see Diagnostic Scales),
which are described in detail below.
One must also consider whether the symptoms are ADHD or evidence of
another disorder. Comorbidity can occur in as many as 80% of ADHD
patients, but one must also consider whether the observed
symptoms are comorbid conditions or if they are the result of a mood
disorder or anxiety disorder and not due to ADHD.
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, and the hyperactive, restless
symptoms of a child with ADHD can manifest as feelings of internalized
restlessness for an adult. 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
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
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.*
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
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.
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).
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.
The Conners Adult ADHD Diagnostic Interview for DSM-IV separately
surveys the presence of the 18 DSM-IV symptoms in both children and
adults. Specific prompts and examples of symptoms are provided for each
query. Impairment in school or work, home, and social settings is also
assessed for children and adults. A definitive diagnosis of ADHD and
subtype of condition can then be established by the information that has
been gathered. The scale begins by asking patients, "What is going
on in your life that leads you to believe you have
Attention-Deficit/Hyperactivity Disorder or ADHD?" From there, it
goes into childhood history, including gestational, delivery,
temperamental, developmental, environmental, and medical history risk
factors. Childhood academic history; adult educational, occupational,
and social/interpersonal histories; and health and psychiatric histories
are queried. Finally, the patient is briefly screened for comorbidity
before specific questioning about ADHD diagnostic criteria begins. The
Conners Diagnostic Interview is available through Multi Health Systems,
Assessment can also begin with Barkley's Current Symptoms
Scale--Self-Report Form, a scale of 18 items that address the symptoms
listed in the DSM-IV diagnostic criteria. Odd-numbered items assess
frequency of inattentive symptoms and even-numbered items assess
hyperactive/impulsive symptoms on a 0-to-3 Likert-type frequency scale
(0 = never or rarely, 1 = sometimes, 2 = often, 3 = very often). Sample
items are "Leave my seat in situations in which seating is
expected" and "Avoid, dislike, or am reluctant to engage in
work that requires sustained mental effort." The scale also asks
patients to report the age of onset for ADHD symptoms and to denote how
often their symptoms interfere with activities in social arenas like
school, relationships, work, and the home. Finally, it addresses
Oppositional Defiant Disorder (ODD) comorbidity with 8 questions about
symptoms of ODD. Barkley also has a Childhood Symptoms
Scale--Self-Report Form; Developmental Employment, Health, and Social
History Form; and Work Performance Rating Scale--Self-Report Forms, all
of which can be sent to the patient to complete before their first
clinic visit. In addition, the Current Symptoms Scale--Other Report Form
provides valuable observer ratings and should be completed by someone
who currently knows the person well. A parent is the ideal person to
complete the Childhood Symptoms Scale--Other Report Form and the
Childhood School Performance Scale--Other Report Form. Together these
scales form a picture of the patient's past and present symptoms and
functioning. The Barkley Scales are contained in Attention-Deficit
Hyperactivity Disorder: A Clinical Workbook, Second Edition by Russell
A. Barkley and Kevin R. Murphy.
In addition to the Brown ADD Scale, there is also a Brown ADD Scale
Diagnostic Form, which goes into much greater detail and can be used for
diagnosing ADHD. The diagnostic interview begins with queries about
clinical history, including impact of symptoms on work, school, leisure,
peer interactions, and self-image. Patients are also asked whether early
schooling was impacted by their symptoms. The clinician asks the patient
about the clinical history of his or her family and about the patient's
physical health, substance use, and sleep habits. The clinician also
obtains collateral data from an observer or significant other and
screens for the full array of comorbid disorders. A Wechsler Adult
Intelligence Scale is administered to gauge whether the patient's
concentration level is below their verbal and spatial capabilities. All
of these considerations, as well as the patients' score on the 40-item
Brown ADD Scale, lead to the diagnosis. The Diagnostic Form is available
from The Psychological Corporation.
Another option for assessing childhood ADHD symptoms is to use the
Kiddie-SADS Diagnostic Interview section on Attention Deficit
Hyperactivity Disorder. The Kiddie-SADS covers the DSM-IV criteria for
ADHD and includes extensive prompts that clinicians can use. For
example, the item, "Makes a lot of careless mistakes," prompts
for the clinician include, "Do you make a lot of careless mistakes
at school? Do you often get problems wrong on tests because you didn't
read the instructions right? Do you often leave some questions blank by
accident? Forget to do the problems on both sides of a handout? How
often do these types of things happen? Has your teacher ever said you
should pay more attention to detail?" The item,
"On-the-go/Acts like driven by motor," prompts for the
clinician include, "Is it hard for you to slow down? Can you stay
in one place for long, or are you always on the go? How long can you sit
and watch TV or play a game? Do people tell you to slow down a
lot?" The Kiddie-SADS is available on the World Wide Web at
Earlier we discussed the possibility that what may seem like ADHD
symptoms may actually be symptoms of another disorder. It is also
important to keep in mind that comorbidity is quite common with ADHD,
affecting as many as 3 in 4 patients, so it should not be surprising if
a patient meets criteria for one or more disorders in addition to ADHD.
The mood disorders (major depression, bipolar disorder, and dysthymia)
have a comorbidity with ADHD ranging from 19% to 37%. For anxiety
disorders, comorbidity ranges from 25% to 50%. The range for alcohol
abuse is 32% to 53%; for other types of substance abuse, including
marijuana and cocaine, it is 8% to 32%. In addition, self-medication
with nicotine and excessive doses of caffeine are often overlooked. The
rate of occurrence with personality disorders is 10% to 20% and for
antisocial behavior is 18% to 28%.[4,12-15] There is a 20%
comorbidity for learning disabilities, particularly auditory-processing
problems like dyslexia and auditory-processing deficits.
To address comorbidity issues, one might administer the Hamilton
Anxiety Scale (HAM-A), the Hamilton Depression Scale (HAM-D), or the
Beck Depression Inventory (BDI), all of which address symptom levels.
The Zung Self-Rating Depression Scale is a diagnostic measure. The BDI
and the Zung are both self-administered, whereas the HAM-A and HAM-D are
When To Refer a Patient Who Has Adult ADHD
Patients may present with anxiety, depressive symptoms, conflicts at
work, school or home, or substance abuse. This can make it quite
difficult to sort out whether ADHD is the primary problem and whether
other disorders are comorbid. The average clinician may
decide to refer the patient for further evaluation to a clinician
experienced in ADHD. If the differential cannot be fully established,
neuropsychological testing can be an option.
Patients may present with symptoms of depression and anxiety rather
than ADHD. The patient may have been nonresponsive to treatment of
depression and anxiety secondary to lack of recognition of the patient's
ADHD. Finally, symptom overlap can occur between the mood-regulating
symptoms of ADHD and the symptoms of anxiety and mood disorders. Taking
a longitudinal history can be helpful in assigning the symptoms to the
appropriate diagnosis. ADHD symptoms tend be more lifelong and less
episodic than those of comorbid disorders. However, assigning symptoms
definitively to one or the other disorder is not always possible.
It is important to note that the diagnosis of adult ADHD is a
clinical decision based on a combination of clinical assessment and
history. The utility of tests in clinical decision-making in medicine
lies in their ability to assist in making diagnostic decisions; however,
the test results themselves must always be interpreted in the context of
the clinical presentation of the patient. This is also true for
neuropsychological testing for adult ADHD. Neuropsychological testing
can often be helpful in establishing the diagnosis and in evaluating
symptom severity when current symptomatology is not fully clear, when
there is substantial comorbidity, when there are concerns over learning
disabilities, or when it is difficult to ascertain whether the disorder
began in childhood. However, testing should not be divorced from the
clinical symptoms and history of the patient, otherwise a substantial
risk for misdiagnosis exists.
Findings regarding specific neuropsychological tests in adult ADHD
have been well reviewed by Faraone and coworkers. Tests
of vigilance by continuous performance testing (CPT), auditory and
visual, have been found to be abnormal in adults with ADHD. Commonly
employed CPTs include the TOVA and Conner's CPT. Both of these tests are
scored in comparison with normal control data. Faraone and colleagues
note that abnormalities exist in perceptual-motor speed (via digit
symbol and coding tests); working memory (via digit span tests); and
verbal learning, semantic clustering, and response inhibition (via
Stroop-Color Word Test). Color-word interference on the Stroop Test has
been shown to correlate with treatment response in an early study of the
norepinephrine reuptake inhibitor atomoxetine.
This discussion provides far from a complete listing of tests
employed in the neuropsychological evaluation of adults with ADHD, but
does include tests that address the impairments in domains noted to
occur in the disorder. Other commonly used tests include IQ tests,
trails A and B, go/no-go protocols, California Verbal Learning Test, and
measures of time estimation. Additionally, tests of academic standing,
such as the Woodcock Johnson, are often used when adults are in school
One area of controversy is determining how well deficits documented
in neuropsychological testing fully translate into functional
impairments. An area of promise in this regard is work by Barkley and
colleagues on abnormalities in driving simulation in
adults with ADHD. Adults with ADHD were noted to have more speeding
citations, license suspensions, crashes, and crashes involving bodily
injury than controls. Additionally, on a computer-simulated driving
test, ADHD adults had more erratic steering, difficulty steering, and
scrapes than controls. A follow-up study by the same group
found similar findings regarding citations and accident history as the
earlier study. Compared with controls, the ADHD cohort also scored lower
on tests of driving rules and decision-making, but not on a simple
driving simulator. Abnormalities on neuropsychological tests did not
correlate well with adverse outcomes, leading the authors to question
their utility as screening tools for driving risks in ADHD adults. Some
measures of impairment in executive functioning did correlate with
accident frequency and citations. These results are preliminary, but do
highlight the need for further study of the measurement of true
functional impairments in ADHD adults via formal tests of
computer-generated driving simulation.
Adults with ADHD are underrecognized and undertreated. Their symptoms
are distinct, though similar, to those of children with the disorder. It
is important to remember that adults are not just grown-up children and
may have differing symptom presentations and impairments. For clinicians
who have little experience screening for or diagnosing adult ADHD,
discerning what constitutes a diagnosis can be confusing. Self-report
rating scales like the ASRS and clinician-administered scales are a
helpful starting point, although they cannot replace an extensive
clinical history and knowing when to refer the patient to a healthcare
professional with adult ADHD expertise. Furthermore, it is critical to
remember that adult ADHD remains a clinical diagnosis.
Neuropsychological testing can be quite helpful in delineating symptoms
and degrees of impairment in adult ADHD patients where diagnostic
uncertainties cloud the patient evaluation.
- Wender PH, Wolf LE, Wasserstein J. Adults with ADHD: an overview.
Ann N Y Acad Sci. 2001;931:1-16.
- Adler LA, Spencer TS, Faraone SV, et al. Adult ADHD Rating Scale.
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Manual of Mental Disorders, Fourth Edition, Text Revision.
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