Assessing Adolescents Using ADHD Rating Scales
Lenard A. Adler, MD (Chair)
Departments of Psychiatry and Child and Adolescent Psychiatry, New York University School of Medicine, and Psychiatry Service, New York VA Harbor Healthcare System, New York
Jeffrey H. Newcorn, MD
Division of Child and Adolescent Psychiatry, Department of Psychiatry, Mount Sinai School of Medicine, New York, New York
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In 2009, the CDC’s National Health Interview Survey1 reported that about 8% of children and adolescents under 18 years old had received a diagnosis of ADHD. About 65% of those who are diagnosed with ADHD as children will continue to have the disorder as adolescents,2 and about 50% will continue to have the full syndrome as adults.3 Accurate diagnosis and treatment of ADHD in children and adolescents is essential to minimize the impairment that ADHD symptoms can cause. Patients also need reassessment over time to determine whether the disorder persists and to measure treatment response. Rating scales are helpful tools for assessing symptoms and ensuring the provision of appropriate treatment to young patients with ADHD.
ADHD in Adolescents
The negative impact of ADHD on adolescent development is far-reaching (AV 1).4,5 Poor planning and organizational skills—symptoms of ADHD associated with executive function impairment—can adversely impact scholastic development. An adolescent with ADHD may be less able to manage the increased cognitive demands presented in school, leading to lower educational achievement and resultant consequences such as changes in peer groups and lowered self-esteem.
Adolescents’ circumstances are similar to those of children, in that they attend school and generally live with their parents. However, adolescence is also the transitional period when children develop psychological autonomy. Adolescents with ADHD, though, may require increased monitoring from parents and school personnel, which can conflict with the developmental trajectory of the adolescent into increased independence.
In general, symptoms of inattentiveness and hyperactivity-impulsivity are equally present in children, while hyperactive symptoms decline as adolescents transition into adulthood.3,4 But problems with inattention and impulsivity can affect developmental tasks in adolescence, and, if present, can lead to negative social consequences. For instance, adolescents with ADHD have an increased risk for incurring traffic violations and for being involved in motor vehicle accidents (AV 2).6
Evaluating ADHD During Adolescence
Children may not be evaluated for ADHD until adolescence for several reasons. The new challenges faced in middle and upper school—such as going to multiple classes, managing a locker, and having a less structured environment—may reveal impairments that were not apparent before. Alternatively, an adolescent’s reaction to an upsetting life event may precipitate an assessment that reveals primary or comorbid ADHD; ADHD may also be identified when adolescents with mood disorders that are not responding to treatment are assessed for comorbidities. In addition to mood disorders, conditions that are often comorbid with ADHD include conduct disorder and ODD.7 An adolescent may self-diagnose and request an evaluation, perhaps due to a friend or family member receiving an ADHD diagnosis. ADHD is also associated with a greater risk for, and an earlier onset of, substance abuse,8 and adolescents may be evaluated due to extensive use of nicotine or caffeine, misuse or diversion of medication, or frank substance abuse.
No litmus test exists to make the diagnosis of ADHD; a diagnosis can only be made through a thorough evaluation that includes a clinical interview. However, rating scales can assist clinicians in evaluating adolescents for the disorder and can provide a framework for discovering the degree of impairment associated with the patient’s symptoms.9 Scales that measure symptom frequency are useful for quantifying a patient’s symptoms at baseline and later measuring symptom improvement to verify that the patient is being treated adequately. Rating scales can help identify specific symptoms that should be targeted during treatment and can also facilitate discussion of ADHD symptoms with patients.
Sympton Rating Scales
Commonly used rating scales that assess symptoms include, but are not limited to, the following:
- The Achenbach Child Behavior Check List has modules for teacher, parent, and self-reports and provides a comprehensive assessment of both competencies and behavioral and emotional problems for children aged 6 to 18 years.
- The Adult ASRS v1.1 Symptom Checklist is an 18-question self-report scale, based on the DSM-IV-TR criteria, that places symptoms in context to gather more accurate information about frequency and severity. The ASRS is a WHO instrument in the public domain that has been translated into many languages and used internationally. The ASRS has undergone preliminary validation for use in adolescents.
- The ADHD Rating Scale-IV is based on DSM-IV diagnostic criteria. The scale has parent and teacher versions and consists of 18 items that rate the frequency and severity of symptoms. Respondents are asked to rate the patient’s behavior based on the previous 6 months, in order to assess the child on current behavior and not on behaviors that may have occurred at a younger age. Gender and age-based norms are provided for scoring the results.
- The BASC-2 is a broad-based set of scales with sections for clinical symptoms, adaptive skills, and executive function. The BASC-2 includes parent, teacher, and self-ratings for 3 age groups, including 12 to 21 years of age, for a comprehensive picture of the adolescent’s behavior.
- The BRIEF has parent-, teacher-, and self-report forms and measures the clinical presentation of executive function for children aged 5 to 18 years.
- The Brown ADD Scales include a frequency-based self-report scale that assesses 5 dimensions of symptoms related to executive function: organizing work, sustaining attention and concentration, sustaining alertness and effort, managing emotions, and using working memory.
- Conners 3rd Edition has parent, teacher, and self-report forms that are available in full-length versions for initial evaluations and comprehensive reevaluations and in short versions that evaluate key symptoms for limited follow-up testing or when time is a factor. The Conners 3 ADHD Index is a 10-item subset of the Conners scales; 5 items measure inattention/overactivity, and 5 items measure aggression/oppositional behavior.
Diagnostic Rating Scales
ADHD instruments more closely linked to diagnostic systems include, but are not limited to, the folllowing:
- The AdolCDS, an analog of the Adult ACDS (a semi-structured interview that includes 84 items), is a physician-administered scale that uses adolescent-specific prompts. The AdolCDS can be obtained by contacting firstname.lastname@example.org.
- The K-SADS-PL ADHD module is a semi-structured interview administered by interviewing the parents and the child and then conducting screening. In the screening interview, 4 symptoms of ADHD are noted, along with a series of child-specific prompts to elicit more complete answers; symptoms are rated on current and past severity.
- The SNAP-IV Rating Scale is based on DSM-IV criteria for ADHD and includes DSM-IV items for ODD and aggression. The scale has 90 questions and is used by teachers and parents.
- The Vanderbilt ADHD Rating Scale (Parent and Teacher versions) is a 55-item scale that rates ADHD symptoms and screens for mood and anxiety disorders, ODD, conduct disorder, and academic performance.
Although neuropsychological tests are not diagnostic of ADHD, they can be helpful to the clinician when evaluating a patient.10 In addition, neuropsychological tests are useful for delineating cognitive dysfunction, determining educational placement, and accessing services in the educational domain for patients with ADHD. Commonly employed tests include the CPT, the Stroop Color and Word Test, and the Trail Making Test.
For Clinical Use
- Be aware that some children with ADHD may not be diagnosed until adolescence, when changing life situations and developmental challenges may reveal impairments that were not apparent in childhood
- Conduct a clinical interview and obtain a longitudinal history of symptoms, establish impairment, and rule out other psychiatric disorders when evaluating an adolescent for ADHD
- Use rating scales to help evaluate patients for impairment, to discern individual symptoms that require targeted treatment, and to measure treatment success in patients with ADHD
ACDS = ADHD Clinical Diagnostic Scale; ADD = attention deficit disorder; ADHD = attention-deficit/hyperactivity disorder; AdolCDS = Adolescent Clinical Diagnostic Scale; ASRS = Adult ADHD Self Report Scale; BASC-2 = Behavior Assessment System for Children, ed. 2; BRIEF = Behavior Rating Inventory of Executive Function; CDC = US Centers for Disease Control and Prevention, CPT = Continuous Performance Test; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; K-SADS = Kiddie-Schedule for Affective Disorders and Schizophrenia; ODD = oppositional defiant disorder; SNAP = Swanson, Nolan, and Pelham; WHO = World Health Organization
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- Bloom B, Cohen RA, Freeman G. Summary health statistics for US children: National Health Interview Survey, 2009. National Center for Health Statistics. Vital Health Stat Series. 2010;10(247).
- Biederman J, Faraone S, Milberger S, et al. A prospective 4-year follow-up study of attention-deficit hyperactivity disorder and related disorders. Arch Gen Psychiatry. 1996;53(5):437–446.
- Kessler RC, Green JG, Adler LA, et al. Structure and diagnosis of adult attention-deficit/hyperactivity disorder: analysis of expanded symptom criteria from the Adult ADHD Clinical Diagnostic Scale. Arch Gen Psychiatry. 2010;67(11):1168–1178.
- Greenhill LL. Diagnosing attention-deficit/hyperactivity disorder in children. J Clin Psychiatry. 1998;59(suppl 7):31–41.
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- Barkley RA, Murphy KR, Kwasnik D. Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics. 1996;98(6 pt 1):1089–1095.
- Barkley RA. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 3rd ed. New York, NY: The Guilford Press; 2006.
- Wilens TE, Biederman J, Mick E, et al. Attention deficit hyperactivity disorder (ADHD) is associated with early onset substance use disorders. J Nerv Ment Dis. 1997;185(8):475–482.
- Murphy KR, Adler LA. Assessing attention-deficit/hyperactivity disorder in adults: focus on rating scales. J Clin Psychiatry. 2004;65(Suppl 3):12–17.
- Doyle AE, Biederman J, Seidman L, et al. Diagnostic efficiency of neuropsychological test scores for discriminating boys with and without attention deficit hyperactivity disorder. J Consult Clin Psychol. 2000;68(3):477–488.