The ADHD specialist will use interviews with the child, adults in the child’s
life (eg parents, teachers and carers) and an independent observer as a first
step in gathering information.
When diagnosing adults, the sources
of information may need to be broadened beyond the patient to include close
contacts, such as a spouse, parents, siblings and, perhaps, friends, co-workers
and employers.
Scales may be used in the community by parents, teachers and primary care
physicians to aid identification of ADHD prior to formal diagnosis. Scales are
also used by the ADHD specialist during formal diagnosis. Examples of scales
commonly used for the diagnosis of ADHD are given in Table 1.
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Overview: It is an 18-item scale based on the DSM-IV criteria for ADHD.
It includes 9 items to assess inattentive symptoms and 9 items to assess
hyperactive and impulsive symptoms.
Clinical application: Symptoms are rated using a 4-point Likert-type
severity scale (0 = none, 1 = mild, 2 = moderate, and 3 = severe).6 |
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Overview: A 24-item scale that covers four factors: attention (6
items), hyperactivity (5 items), social skills (7 items), and oppositional
behaviour (6 items). For greater diagnostic accuracy, the ACTeRS teacher rating
form can be supplemented with the ACTeRS parent form and the ACTeRS self-report.
The ACTeRS parent form includes an additional scale focusing on early childhood
behaviour, whereas the ACTeRS self-report form includes 35 items and covers
three factors: attention, hyperactivity/impulsivity and social adjustment.
Clinical application: This scale evaluates how the child compares with
other children. Items are scored using a five-point scale, ranging from almost
never to almost always, with item scores totalled and converted to percentiles
using a profile sheet for the different scales. A separate profile is provided
for boys and girls. The lower the percentage, the more significant the
difference.7
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Overview: The Barkley home and school situations questionnaires are
designed to gather information from both parents and teachers, since the DSM-IV
states that symptoms of ADHD must be present in at least two environments. The
home situation questionnaire evaluates how ADHD disrupts normal home situations
such as meal time. Parents complete this questionnaire by rating problems in 16
different areas on a scale of 1-9. The school situation questionnaire is
completed by teachers and evaluates the child on 12 common school situations.
Clinical application: Results from both the Barkley home and school
situations questionnaires are compared with the DSM-IV criteria for the
diagnosis of ADHD.8 |
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Overview: The Brown ADD scales explore the executive cognitive
functioning aspects of cognition associated with ADHD, and are available for
primary/preschool (3 to 7 years) and school-age children (8 to 12 years),
adolescents (12-18 years) and adults. Brown ADD scales can be used for
screening, as part of a comprehensive diagnosis, and for monitoring of treatment
responses in a wide range of educational, clinical, and managed care settings.
Clinical application: It consists of a 40-item self-report
questionnaire grouped into five clusters of conceptually related symptoms of the
condition: organising and activating to work, sustaining attention and
concentration, sustaining energy and effort, managing affective interference,
and utilising ‘working memory’ and accessing recall.
Responses recorded using the Brown ADD scales are totalled and interpreted into
three categories: ADD possible but not likely, ADD probable but not certain, and
ADD highly probable.9 |
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Overview: This scale is for parents or other individuals who know the
child well to rate a child’s problem behaviours and competencies. Versions of
the scale are available for different age groups up to the age of 18 years.
Clinical application: Responses to all questions are recorded on a
Likert scale (0 = not true, 1 = sometimes true, 2 = very or often true), and a
total score from all questions is derived. Similar questions are also grouped
into various ‘syndromes’, with their respective scores summed to produce a score
for that syndrome. Tables are provided to determine whether the scores obtained
represent normal, borderline, or clinical behaviour.10 |
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Overview: A numeric scale (1–100) used by healthcare professionals to
rate the general functioning of children
<18 years at home, at school and among peers.
Clinical application: The single numerical score represents the
severity of disturbance and ranges from 1 (most impaired) to 100 (healthiest). A
score of 61–70 indicates that the child has some difficulty in a single area but
is generally functioning reasonably well. Scores >70
are considered to be in the normal range, whereas those on the low end of the
continuum indicate a need for constant supervision (1–10) or considerable
supervision (11–20).11 |
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Overview: Available in long and short versions, this is a paper-based
screening questionnaire designed to be completed by parents and is intended to
assess children aged 3-17 years. Interpretation of the scale should be done by a
healthcare professional.
Clinical application: As a rule, T-scores above 60 are cause for
concern and have interpretive value. Interpretable scores range from a low
T-score of 61 (mildly atypical) to above 70 (markedly atypical). However, this
information should not be used in isolation to make a diagnosis.12 |
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Overview: Available in long and short versions, and is designed to be
completed by teachers for the assessment of children aged 3-17 years.
Interpretation of the scale should be done by a healthcare professional.
Clinical application: T-scores derived from the CTRS-R
>60 are cause for concern and have interpretive value. Interpretable
scores range from a low T-score of 61 (mildly atypical) to above 70 (markedly
atypical). However, this information should not be used in isolation to make a
diagnosis.12 |
Inattention/Overactivity With Aggression (IOWA) Conners’ Teacher Rating
Scale13 |
Overview: This is a 10-item scale developed to separate the inattention
and overactivity ratings (5 items) from oppositional defiance (5 items).
Clinical application: Information not available. |
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Overview: A 10-item questionnaire for detecting developmental and
behavioural problems in children aged 0-8 years. It can be used as a
developmental screening tool, and as an informal means to elicit and respond to
parental concerns.
Clinical application: PEDS is completed by parents, with scores
transferred onto a PEDS score form. The appropriate path, based on the
number/type of concerns identified, is then decided using the PEDS
interpretation form.14 |
Swanson, Kotkin, Atkins, M-Flynn and Pelham scale (SKAMP)43 |
Overview: A 10-item scale that measures impairment of functioning at
school. Behavioural subscales of attention (SKAMP-A) and deportment (SKAMP-D)
are assessed based on direct observations of behaviour in the classroom.
Clinical application: Teachers rate the severity of 10 items (6 for
attention, such as difficulty getting started on classroom assignments; and 4
for deportment, such as difficulty remaining quiet according to classroom rules)
on a 4-point scale: 0 = not at all, 1 = a little, 2 = pretty much, to 3 = very
much.16 Higher SKAMP scores are indicative of more severe symptoms.17 |
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Overview: It contains 90 items and covers symptoms of ADHD, ODD and
aggression.
Clinical application: SNAP-IV is based on a 0-3 rating scale: not at all =
0, a little = 1, quite a bit = 2, and very much = 3. Subscale scores on the
SNAP-IV are calculated by summing the scores for items in the subset and
dividing by the number of items in that subset. Tentative 5% cut-off values for
both teacher and parent assessments are provided for each subset.18 |
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Overview: The SWAN Rating Scale was developed based on SNAP-IV. It has
30 items and includes ADHD symptoms and symptoms of ODD.
Clinical application: Each item is scored based on observations over
the past month. Abilities are compared with children of the same age using a
7-point scale (-3 to +3), where 0 is average, -3 is far below and +3 is far
above children of the same age.19 |
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Overview: A DSM-IV based scale that comprises separate parent (55
items) and teacher (43 items) rating forms for use with children aged 6-12. It
provides information about symptoms which may be used to diagnose ADHD by
breaking ADHD down by its various subtypes: inattentive, hyperactive/impulsive
or combined. The Vanderbilt scale also looks for symptoms of frequent
co-morbidities, such as ODD, CD, anxiety, and depression; and also evaluate
school function, with separate questions about academic and behavioural
performance.
Clinical application: Inattention requires ≥6
counted behaviours from questions 1–9 for indication of the predominantly
inattentive subtype, whereas hyperactivity/ impulsivity requires
≥6 counted behaviours from questions 10–18 for
indication of the predominantly hyperactive/impulsive subtype. Combined subtype
requires ≥6 counted behaviours each on both the
inattention and hyperactivity/impulsivity dimensions. ODD and CD require
≥3 counted behaviours from questions 19–28. Anxiety or depression
symptoms require ≥3 counted behaviours from
questions 29–35. The performance section is scored as indicating some impairment
if a child scores 1 or 2 on at least one item.22 |
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Overview: The Weiss Functional Impairment Rating Scale for parents is
a questionnaire that examines impairment in each of the major domains.
Clinical application: The instrument uses a Likert scale, with any item
rating 2 or 3 considered clinically impaired. For clinical purposes, when
defining impairment for DSM-IV, clinicians can consider that any domain with at
least two items scored 2, one item scored 3 or a mean score >1.5 as impaired.20 |
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Overview: The Weiss Functional Impairment Rating Scale self-report is
a questionnaire that examines impairment in each of the major domains.
Clinical application: The instrument uses a Likert scale, with any item
rating 2 or 3 considered clinically impaired. For clinical purposes, when
defining impairment for DSM-IV, clinicians can consider that any domain with at
least two items scored 2, one item scored 3 or a mean score >1.5 is impaired.20 |
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Overview: It consists of 18 DSM-IV-TR criteria, amongst which are
questions that are most predictive of symptoms consistent with ADHD.
Clinical application: Part A of the symptom checklist comprises 6
questions that are most predictive of ADHD; the remaining 12 questions are
included in Part B. Four or more check marks in the darkly shaded boxes within
Part A indicate symptoms highly consistent with ADHD in adults. The frequency
scores on Part B provide additional cues - pay particular attention to marks
appearing in the dark shaded boxes. However, no total score or diagnostic
likelihood is utilised for these twelve questions.21 |
*It is important to note that the assessment scales used to diagnose ADHD may
vary from country to country, the table above includes a summary of the most
common scales used globally.
An understanding of a patient’s adjustment at school or an adult’s performance
in the workplace is an important factor in the assessment process.
In addition, a clinical assessment or examination of medical records may be
useful to rule out an undiagnosed disorder with symptoms that, in rare
instances, could mimic those of ADHD, such as hearing impairment, epilepsy or
thyroid disorder.