A Practical Guide for Diagnosing Adult Attention Deficit Hyperactivity Disorder

Lorin Leithead, MS, FNP; Donna Freeborn, PhD, FNP-BC


Journal for Nurse Practitioners. 2013;9(10):688-694. 

In This Article

Current Symptom Instruments

Adult ADHD Self-Report Scale (ASRS)

Produced by the World Health Organization (WHO),[13] the ASRS symptom checklist is an 18-item instrument that uses symptoms identified by the DSM-4.[13] There is also an ASRS version of 6 items that has been proven effective for screening purposes. Both ASRS versions are appropriate for adult ADHD assessment and use current symptoms in a self-report format.[13,14]

Pros Permission is granted to use the instrument free of charge, making it cost effective as a screening instrument. It is based on the DSM-IV symptoms, allowing the PCP to cross-reference the DSM-IV for diagnostic purposes. The screening version of 6 questions is useful in that it can save PCP and patient time by quickly ruling in or out a potential adult ADHD diagnosis. An additional strength is that the ASRS has been translated into multiple languages: Chinese, Danish, Dutch, Finnish, French, German, Hebrew, Japanese, Korean, Norwegian, Portuguese, Russian, Spanish, and Swedish.[13]

Cons The ASRS measures frequency of symptoms but does not assess severity of symptoms.[14]

Brown Attention-Deficit Disorder Scales (BADDS)15

The 40-item BADDS is a self-report instrument for adults 18 years old or older that uses current symptom assessment.[15] It assesses symptoms used in DSM-IV criteria and further assesses 5 other criteria: organization, maintaining attention, sustaining energy, mood and sensitivity, and working memory.[15]

Pros The PCP is able to use questions in an interview style.[15] BADDS is also an effective instrument for monitoring treatment of attention deficit disorder (ADD) patients.[15] To help score the instrument and save time, there is a computer program for purchase; however, it does require the PCP to manually enter the data.

Cons This instrument only assesses ADD, whereas hyperactivity and impulsivity types are not assessed.[15] Purchase is required for each assessment instrument, thus increasing the long-term cost of using this instrument.

Conners' Adult ADHD Rating Scales (CAARS)

The third instrument was developed to measure ADHD symptoms in adults 18 or older.[11] It is helpful that assessment of ADHD symptoms addressed in the tool links directly to the DSM-IV criteria.[11] The items in CAARS are designed to assess current ADHD symptoms and not those in the individual's childhood.[11,16] CAARS uses both a self-report form and observer-report form, providing the PCP additional information about the patient's symptomatology.[11]

Pros This instrument is based on DSM-IV criteria.[11] There are 3 variations of the instrument: a long, short, and screening version.[11] Each version has a self-report form to be completed by the individual and observer-report form to be completed by parent, spouse, friend, or coworker, which gives the PCP further information on the symptomatology of the patient.[11] There is a built-in inconsistency index that suggests appropriate follow-up questions to clarify disparities.[11] There is also a computer version of the assessment.

Cons The PCP must become familiar with 3 different instruments so each can be used when appropriate. Each instrument, as well as the computer version, requires separate purchase, increasing the long-term cost of using this instrument.

Current Symptoms Scale (CSS)

The fourth instrument is a part of the Barkley manual.[17] It is an 18-item instrument that uses DSM-IV criteria and an additional 18 items that evaluate symptoms in 10 settings in which ADHD symptoms might occur: home, work, social interactions, community activities, education, relationships, money management, driving, leisure/recreation, daily responsibilities.[17] Eight additional questions rate behavior such as temper, arguing, defying rules, annoying people, blaming others, being annoyed by others, anger, and feeling spiteful/vindictive.[17] The CSS is designed for assessing adults 18 and older, is a self-report, and measures current symptoms.[17]

Pros Permission is granted for duplicating the instrument after purchase of the manual, making the long-term cost of using this instrument minimal.[17] The DSM-IV symptom criteria were used in creating the CSS.[17] The CSS is part of the Barkley ADHD workbook that also includes the childhood symptoms scale and a structured interview guide, which provides inexperienced PCPs assistance with diagnosing ADHD.

Cons The CSS is sold as a group of instruments, requiring the purchase of the complete group.

College ADHD Response Evaluation (CARE)

The last instrument is a self-report and parent-report assessment tool specifically designed for evaluation of college students (2- or 4-year postsecondary school).[18] There is no specific age requirement, yet the normed age of those tested with CARE was 17–23.[18] CARE was developed from the DSM-IV.[18]

Pros CARE has a built in Comorbidity Screener that alerts the practitioner of possible comorbid conditions (eg, anxiety disorders, mood disorders, somatic disorders, disruptive behavior disorders, and substance abuse), allowing the PCP to rule them out.[18]

Cons Because this instrument is only used for college aged individuals, it requires the PCP to use another instrument if their patient does not fall into that specific age range. (For more details see Table 1 .)