03_11_Rösler_EAPCN_S_1001 06.09.
2006 12:22 Uhr Seite 3
Eur Arch Psychiatry Clin Neurosci (2006) 256 [Suppl 1]:I/3–I/11
M. Rösler · W. Retz · J. Thome · M. Schneider · R.-D. Stieglitz · P. Falkai*
Psychopathological rating scales for diagnostic use in adults
with attention-deficit/hyperactivity disorder (ADHD)
Received:  / Accepted:  / Published online: 
■ Abstract The diagnosis of attention-deficit hyperac-
tivity disorder (ADHD) in adults is a complex procedure
which should include retrospective assessment of child-
hood ADHD symptoms either by patient recall or third
party information, diagnostic criteria according to
DSM-IV, current adult ADHD psychopathology includ-
ing symptom severity and pervasiveness, functional im-
pairment, quality of life and comorbidity. In order to ob-
tain a systematic database for the diagnosis and
evaluation of the course ADHD rating scales can be very
useful. This article reviews rating instruments that have
found general acceptance.
The Wender-Utah Rating Scale (WURS) and the
Childhood Symptoms Scale by Barkley and Murphy try
to make a retrospective assessment of childhood ADHD
symptoms. The Connors Adult ADHD Rating Scales
(CAARS), the Current Symptoms Scales by Barkley and
Murphy (CSS), the Adult Self Report Scale (ASRS) by
Adler et al. and Kessler et al. or the Attention Deficit Hy-
peractivity Disorder – Self Report Scale (ADHD-SR by
Rösler et al.) are self report rating scales focusing mainly
M. Rösler · W. Retz · M. Schneider · P. Falkai
University Hospital of the Saarland, Neurocenter
66421 Homburg/Saar, Germany
J. Thome
University of Wales Swansea
The Medical School
Psychiatric Department, UK
R.-D. Stieglitz
Psychiatric Outpatient Department
University Hospital Basel, Switzerland
Prof. Dr. med. Michael Rösler (
)
Neurozentrum – IGPUP
Universitätsklinikum des Saarlandes
66421 Homburg/Saar, Germany
Tel.: +49-6841/1626350
Fax: +49-6841/1626335
E-Mail: michael.roesler@uniklinik-saarland.de
* The authors thank Dr. Frederick Reimherr, University of Utah, Salt
Lake City, USA for critical advice.
DOI 10.1007/s00406-006-1001-7
on the DSM-IV criteria. The CAARS and the CSS have
other report forms too. The Brown ADD Rating Scale
(Brown ADD-RS) and the Attention Deficit Hyperactiv-
ity Disorder-Other Report Scale (ADHD-OR by Rösler
et al.) are instruments for use by clinicians or significant
others. Both self rating scales and observer report scales
quantify the ADHD symptoms by use of a Likert scale
mostly ranging from 0 to 3. This makes the instruments
useful to follow the course of the disease quantitatively.
Comprehensive diagnostic interviews not only evaluate
diagnostic criteria, but also assess different psy-
chopathological syndrome scores, functional disability
measures, indices of pervasiveness and information
about comorbid disorders. The most comprehensive
procedures are the Brown ADD Diagnostic Form and
the Adult Interview (AI) by Barkley and Murphy. An in-
strument of particular interest is the Wender Reimherr
Interview (WRI) which follows a diagnostic algorithm
different from DSM-IV. The interview contains only
items delineated from adult psychopathology and not
derived from symptoms originally designed for use in
children.
Other instruments focus on functional impairment,
quality of life, comorbid disorders, gender effects and
specific psychopathological models.
■ Key words ADHD assessment · rating scales ·
diagnosis of ADHD · diagnostic interview
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a
common psychiatric condition usually manifesting it-
self in childhood with a prevalence of 6–9% in school-
age children (Barkley and Murphy 1998). Contrary to
former assumptions, the symptoms and functional
deficits in many affected adolescents are not out grown,
EAPCN 1001
but continue into adult life. Follow-up studies have
shown that in 60% of affected subjects, ADHD may per-
sist either as the residual type or as a full clinical disor-
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der (Weiss et al. 1985, Mannuzza et al. 1993, Barkley
2002). ADHD, thus, displays all characteristics of a
chronic disease. According to current epidemiological
studies, the prevalence of adult ADHD in the US is ap-
proximately 4% (Kessler et al. 2005a), a rate similar to
previous findings in college students (Heiligenstein
et al. 1998) and driver’s license applicants (Murphy and
Barkley 1996). Based on these prevalence rates, ADHD
probably represents one of the most common mental
conditions in adults.
ADHD is not limited to a specific social class and
does not depend on the level of education (Barkley and
Murphy 1998). In epidemiological samples male pa-
tients outnumber females by a ratio of 2–3:1 in child-
hood. In adults the gender ratio tends to be more equal.
The concepts behind, the criteria for, and the terms of
the syndrome of ADHD have changed frequently. A se-
ries of research efforts considerably influenced by Paul
Wender (1995) helped shape the diagnostic concept of
attention deficit disorders as defined in the DSM-III
(APA 1980) and later classification systems. Using the
diagnostic term “attention deficit disorder (ADD)”,
DSM-III emphasized the core features of inattention and
impulsivity. In this concept, hyperactivity is not essen-
tial for the diagnosis although it is often present. DSM-
III-R (1987) introduced several modifications. Essential
criteria were inattention, impulsivity and hyperactivity.
DSM-IV (1994) separated the symptoms of ADHD into
the two domains “inattention” and “hyperactivity/im-
pulsivity”. Each domain contains nine psychopatholog-
ical symptoms. Three diagnostic subtypes were identi-
fied (ADHD – combined type, ADHD – predominantly
inattentive type, and ADHD – predominantly hyperac-
tive-impulsive type). If at least six symptoms of inatten-
tion and six of hyperactivity are present, ADHD com-
bined type should be diagnosed. If at least six symptoms
of inattention but less than 6 of hyperactivity/impulsiv-
ity can be detected, the diagnosis “ADHD inattentive
type” should be given. ADHD hyperactive/impulsive
type is diagnosed if at least 6 symptoms of hyperactiv-
ity/impulsivity are present but fewer than six of inatten-
tion.
The set of eighteen DSM-IV symptoms characteriz-
ing the different ADHD types was originally developed
for the use in child psychiatry. As far as we know, no val-
idation study in adults has ever been performed. Thus,
the question remains whether the DSM-IV criteria are
adequate to characterize adult ADHD. Some of the DSM-
IV symptoms are clearly inappropriate such as “runs
and climbs excessively” or “has difficulty playing qui-
etly” (Wender 1995, Murphy & Barkley 1996, McGough
& Barkley 2004).
Almost all of the eighteen DSM-IV symptoms repre-
sent everyday life behavior which can be observed by
parents, teachers or other persons in close contact with
the individual suffering from ADHD. The subjective ex-
periences of the patient are not part of these diagnostic
criteria. This is readily understandable in child and ado-
lescent psychiatry where the ability and accuracy of self
recognition of psychopathological symptoms is limited.
In adult psychiatry, however, the subjective experiences
play a substantial role in psychopathology. For example,
a significant number of the diagnostic symptoms in
anxiety or affective disorders are based on subjective ex-
periences.
Under these circumstances, it is important to con-
sider whether symptom criteria, which specifically focus
on adult ADHD psychopathology, should be incorpo-
rated in the diagnostic process.
On the other hand, the DSM-IV symptom lists have
been used successfully in a number of studies on adult
ADHD. Mainly in pharmacological trials, in studies with
structural and functional MRI, and in molecular genetic
research the patient selection and description has been
made according to the diagnostic criteria of DSM-IV
(McGough and Barkley 2004).
The diagnosis of adult ADHD is a clinical decision-
making process (Faraone and Biederman 1998). The
clinician establishes the diagnosis based on the results of
a comprehensive examination assessing psychopathol-
ogy, functional impairments, pervasiveness of the dis-
ease, age of onset and the absence of other disorders
which could better explain the symptoms. No neurobio-
logical or any other test (e. g., neuropsychological test) is
available so far to determine on an individual basis
whether ADHD is present or not (Faraone 2005b). Apart
from the more fundamental question about the suitabil-
ity of the DSM-IV diagnostic criteria, there are addi-
tional difficulties regarding the diagnostic process in
adults.
One of these problems is the retrospective determi-
nation of childhood ADHD symptoms in individuals
who were never referred for a child-psychiatric exami-
nation despite the presence of ADHD symptoms. If in
these cases a parent or a person who provided child care
is available, information about the symptoms during
school age can be obtained. In the absence of an infor-
mant, the diagnostician must rely on the individual’s
ability to recall ADHD symptoms in childhood. A recent
study has shown that the validity of such information is
questionable (Mannuzza et al. 2002).
Further difficulties may arise while assessing the per-
vasiveness of the disease. The psychopathology should
manifest itself in different life situations and not only in
particular domains, e. g., at work or at school. The col-
lection of information about the psychopathology in
different fields of every-day life is an important factor of
the diagnostic process.
A fundamental diagnostic criterion of ADHD ac-
cording to DSM-IV is the presence of sufficient symp-
tom severity to cause significant functional deficits in
school or work performance, marital life, child parent-
ing, leisure activities etc. A diagnosis of ADHD can only
be made if there is substantial evidence for such a func-
tional impairment.
A very important finding in adult ADHD research is
the fact that ADHD alone, without any other comorbid
disorder, occurs in a minority of cases. In clinical ADHD
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populations, as many as three in four patients are suf-
fering from one or more disorders in addition to ADHD
(Faraone and Biederman 1998). The number of comor-
bid conditions which have been recognized to be signif-
icantly associated with ADHD, is continuously rising.
Beside the more classical comorbid conditions such as
learning disorders (LD), conduct disorder (CD), opposi-
tional defiant disorder (ODD), mood disorders, sub-
stance-use disorders and personality disorders, other
syndromes like restless legs, bulimia, posttraumatic
stress disorder, and obsessive compulsive disorder have
been found more often in ADHD patients than in
healthy controls or individuals with other psychiatric
disorders (Pliszka 1998, Biederman 2005, Faraone
2005a). Efficient treatment recommendations clearly re-
quire careful consideration of the individual comorbid-
ity structure.
In summary, the diagnostic process consists of dif-
ferent stages as mentioned above and the clinician is
confronted with a complex assessment procedure.
Different aspects of the diagnostic procedure in adult
ADHD:
 Childhood symptoms
 Diagnostic criteria (DSM-IV, ICD-10 research ver-
sion, Utah criteria)
 Current adult ADHD psychopathology, symptom
severity and pervasiveness
 Functional impairment and quality of life
 Comorbidity
Therefore, one may ask what kind of assessment meth-
ods are available to help collect a database to support a
complete diagnostic assessment.
Psychopathological rating scales
These scales provide a mechanism to collect patient data
in a consistent manner. Most scales fall into two types:
self-rated scales and observer-rated. In both types of
scales, more or less precisely defined ADHD symptoms
can be quantified in different levels of severity. In this
publication it is not possible to discuss in detail all scales
which have been developed in this field of research. We
will therefore focus on scales that have found general ac-
ceptance.
■ Retrospective assessment of childhood ADHD
symptoms
An ongoing debate refers to the validity of such scales
(Murphy and Schachar 2000, Mannuzza et al. 2002).
There seems to be growing agreement that such an as-
sessment procedure can be valid if the limitations of the
instruments regarding sensitivity and specificity are
taken into account together with population character-
istics, in particular the prevalence of the disorder to di-
agnose.
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The first such scale was the Wender Utah Rating Scale
(WURS, Wender 1995). The original version contains 61
questions. The adult ADHD patient is asked about his
symptoms when he was aged eight to ten. The items of
the WURS do not reconstruct the DSM-IV symptoms.
They focus on the concept of the Utah criteria (Wender
1995). Inattention, hyperactivity and impulsivity to-
gether with emotional dysregulation and conduct prob-
lems are contents of the WURS. There is a short version
with 25 items (Ward et al 0.1993) which can be adminis-
tered more easily. The WURS is one of few ADHD scales
which have been translated into other languages. Cur-
rently in use are English, Spanish, Italian and German
versions (Groß et al. 1999, Fossati et al. 2001, Rodriguez-
Jimenez et al. 2001, Retz-Junginger et al. 2002). The
American as well as the German short version with 25
items (WURS-k) have been validated on national sam-
ples of patients and controls. The factor structure has
been evaluated (Stein et al. 1995, Retz-Junginger et al.
2003).
The Childhood Symptom Scale – Self Report Form
(ChSS-SRF) by Barkley and Murphy (1998) focuses on
the retrospective assessment of the eighteen DSM-IV
criteria. Additionally, eight items concerning functional
disabilities, eight items referring to symptoms of ODD
and fifteen items to CD are checked with the patient,
thus giving the opportunity to make ODD and CD diag-
noses which are summarised under the DSM-IV main
heading “disruptive behaviors”. Table 1 displays the
WURS as well as the CSS-SRF and their basic character-
istics.
■ ADHD rating scales for current psychopathology
The majority of the rating scales are designed to assess
the eighteen diagnostic criteria of DSM-IV. Some rating
scales check for additional psychopathological symp-
toms. The Conners Adult ADHD Rating Scales (CAARS,
Conners et al. 1999) have found general acceptance.
They include a set of self-report (CAARS-SR) and ob-
server-report scales (CAARS-OR). Both types have a
long, a short and a screening version. A technical man-
ual offers gender and age dependent norms (Conners
et al. 1999). The psychometric properties including in-
ternal consistency, different aspects of validity and reli-
ability have been determined in detail. The CAARS allow
not only the calculation of DSM-IV oriented inattention,
impulsivity and hyperactivity scores, but also measures
of emotional lability and problems with self-concept. In
the atomoxetine trials (Michelson et al. 2003) a third
CAARS type was used called the CAARS-Investigator
(CAARS-INV). This is about a thirty item version com-
pleted by an interviewer with “cue” questions. No relia-
bility and validity data have been published on this man-
ner of administering the CAARS.
In comparison to the CAARS, the Current Symptoms
Scales (CSS-OR and CSS-SR) by Barkley and Murphy
(1998) focus exclusively on the DSM-IV defined psy-
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Table 1 Scales for the retrospective assessment of childhood ADHD psychopathology
Scale, author Mode
Items
Factors
WURS, Wender SRF, 61 + 25 item Versions,
0–4 scale, Utah criteria,
different factor solutions
Childhood Symptoms SRF, 18 DSM-IV items, 0–3 scale,
Scale – SRF, 8 items social functioning,
Barkley & Murphy 8 items ODD, 15 items CD
Eng English; Ger German; Hisp Hispanic; Ita Italian; SRF Self Report Form; Rel Reliability; Pts Points; SD Standard Deviation; ODD Oppositional Defiant Disorder; CD Conduct
Disorder; Min Minutes
chopathology. Both scales – others report form and self-
rating scale – use the eighteen DSM-IV items, which can
be quantified from 0 to 3. A specific feature of the two
CSS scales is the opportunity to rate ADHD-interfered
functional deficits and the symptoms of ODD. The re-
sults of the assessment can be interpreted by using age
and gender specific norms.
The Adult Self-Report Scale (ASRS) and the ASRS
Screener are official instruments of the WHO. They have
been developed by Adler et al. (2003a) and Kessler et al.
2005b). The ASRS contains eighteen DSM-IV items. The
screener has four inattention items and two hyperactiv-
ity items, which highly correlate with the full scale ASRS.
The items can be scaled from 0 to 4. Basic psychometric
properties like internal consistency and convergent va-
lidity have been determined. These scales are available
in different languages.
The ADHD Rating Scale-IV (ADHD-RS-IV, DuPaul
et al. 1998) is a scale originally designed for children and
adolescents. The scale has been used in studies with
adults, particularly in pharmacological trials. Together
with the English version, a Spanish scale has been pub-
lished. The ADHD-RS is an informant-based scale, in
which each item is rated from 0 to 3. The psychometric
properties have been evaluated. The handbook (DuPaul
et al. 1998) gives age- and gender-specific norms and ad-
vice regarding the clinical interpretation in children and
adolescents. A synopsis of the rating scales is given in
Table 2.
The Brown ADD Rating Scale (Brown ADD-RS,
Brown 1996) was developed before the DSM-IV concept
of ADHD was published. The design of the scale is pri-
marily oriented on inattention. Hyperactivity and im-
pulsivity do not play an important role. Instead, other
symptom domains can be assessed, such as organizing
work, managing affective interference, sustaining en-
ergy and effort and working memory.
The ADHD-SR (German: ADHD-SB) and the ADHD-
OR (German: ADHD-DC) were originally designed for
the use in German-speaking countries (Rösler et al.
2004a). The principles of construction of the ADHD-SR
are similar to those of the ASRS (WHO, Adler et al.
Seite 6
Normative data Administration (min) References
psychometric Cut-off:
Properties Language:
Different populations, 10–20 min, Wender (1995), Ward et al. (1998),
int. consistancy, WURS-k: 30 pts Retz-Junginger et al. (2002, 2003)
reliability, validity WURS-Ward: 36 pts
Eng, Hisp, Ita, Ger
Age- and gender-specific 20 min Barkley & Murphy (1998)
norms 1.5 SD from mean of gender
and age norm
Eng, Ger
2003a). In the case of the ADHD-OR, the selection and
graduation of the eighteen DSM-IV items was done us-
ing the ADHD-RS as a model. The ADHD-SR and
ADHD-OR contain the eighteen DSM-IV items of inat-
tention, hyperactivity and impulsivity and graduate
them from 0 to 3. Both scales have been evaluated in dif-
ferent German populations. The generation of DSM-IV
and ICD-10-RC (Research Criteria) diagnoses is possi-
ble. Psychometric properties including internal consis-
tency, retest reliability and convergent and divergent va-
lidity were evaluated.
Diagnostic interviews
In comparison to rating scales, the construction of
structured diagnostic interviews aims at a higher degree
of standardization in order to reach high levels of inter-
rater reliability and to control for investigator-based
variance. The diagnostic process begins with standard-
ised questions and prompts which ones should be ap-
plied to the patient. Usually the quantification of the in-
formation shows a higher degree of standardisation. All
interviews listed in Table 3 are investigator-adminis-
tered instruments.
The first interview to diagnose adult ADHD was de-
signed by Paul Wender (1995). The instrument was orig-
inally published as Targeted Attention-Deficit Disorder
Symptoms Rating Scale (TADDSRS). Later the interview
was named Wender-Reimherr Adult Attention Deficit
Disorder Scale (WRAADDS) with reference to the main
authors responsible for the development of the inter-
view. The underlying diagnostic concept goes back to
the time before DSM-III was published. The Wender
Utah criteria contain inattention and hyperactivity/rest-
lessness as mandatory syndromes, which must always be
present for an ADHD diagnosis. Impulsivity, disorgani-
zation, affective lability, stress intolerance and temper,
although present very frequently, are additional symp-
toms. Two of the five additional symptoms are necessary
for the diagnosis. The WRAADDS was evaluated in de-
tail regarding its psychometric properties. Population
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Table 2 ADHD rating scales for the assessment of adult psychopathology

Scale, author Mode Normative data Administration References

Items psychometric Cut-off
Factors Properties Language

CAARS, 3x SRF + 3x ORF, 66 + 30 + Age and gender specific norms, 10–20 min, different levels Conners et al. (1999)
Conners et al. 26 Items, DSM-IV syndromes + syndrome profiles, different of interpretation including
emotional lability + problems aspects of reliability and validity ADHD index, Eng, Ger
self-concept

Current Symptoms 1x SRF + 1x ORF, 18 DSM-IV items, Age- and gender-specific norms 15 min, Barkley and Murphy (1998)
Scales, 0–3 scale, 10 items social dysfunction, for ADHD and ODD Cut-off: 1.5 SD above mean
Barkley & Murphy 8 items ODD Eng, Ger

Brown, ADD ORF, 40 items, 5 symptom dimensions: Different population norms, t-norms 15 min, Brown T. (2005)
Rating Scale inattention, organising work, sustaining 7 scores internal consistency, Cut-off: 50 pts
Brown ADD-RS energy, managing affective interference, specificity and sensitivity Eng, Ger
working memory, 0–3 scale based on
behaviour frequencies

Adult Self Report SRF, 6 DSM-IV items, 4 inattention, Internal consistency, convergent 3 min, 4 items positive WWW. med.nyu.edu/
Scale ASRS-V1.1, 2 items, 0–4 scale hyperactivity validity, interrater reliability Eng, Fr, Ger, Hisp, Psych/training/Adhd.html
Screener, Adler, WHO instrument WHO
Kessler Spencer

Adult Self Report SRF, 18 Items, 0–4 saling, DSM-IV Internal consistency, inter-rater 5 min, Adler et al. (2003a)
Scale, ASRS-V1.1. syndromes reliability DSM-IV rules WHO instrument WHO
Adler et al., WHO Eng, Fr, Ger, Hisp

ADHD-RS-IV, ORF, 18 items, DSM-IV, 0–3 scale Normative data for children and 8 min DuPaul et al. (1998)
DuPaul et al. adolescents DSM-IV rules
Eng, Hisp

ADHD-SB + 1x SRF, 1x ORF, 18 DSM-IV items, Interrater reliability, convergent 8 min, Rösler et al. (2004a)
ADHD-DC, 0–3 scale, DSM-IV syndromes validity, factor structure, specificity, DSM-IV rules, Ger
Rösler et al. sensitivity

Eng English; Ger German; Hisp Hispanic; Fre French; SRF Self Report Form; Rel Reliability; SD Standard Deviation; ODD Oppositional Defiant Disorder; Min Minutes

norms, reliability and validity measures as well as factor
analyses have been investigated in American and Ger-
man populations (Reimherr 2004, Wender 2004, Rösler
et al. 2006).
The Conners’ Adult ADHD Diagnostic Interview for
DSM-IV (CAADID, Epstein et al. 2001) contains two
parts. Part I collects comprehensive data about different
risk factors as well as the school, psychiatric, family, oc-
cupational, and interpersonal history. Part II assesses
the current presence of the eighteen DSM-IV items dur-
ing adulthood and their past occurrence during child-
hood. Further information is obtained regarding age of
onset, pervasiveness and functional impairment inter-
fering with the disease. Typically the CAADID is used in
pharmacological and psychotherapeutic treatment
studies to evaluate potential patients for the inclusion or
exclusion. Normative data and measures of the psycho-
metric properties of the instruments were published in
the technical manual.
The Adult Interview (AI) by Barkley and Murphy
(1998) is an instrument that focuses not only on the
DSM-IV items but also functional impairment,ODD,CD
and antisocial personality disorder (ASP) symptoms.
Family and psychiatric history together with diagnostic
criteria of anxiety and mood disorders are parts of the
evaluation process. Normative data and details of the
psychometric properties are not given in the clinical
workbook (Barkley and Murphy 1998). In comparison
with other interviews, the AI is a comprehensive instru-
ment that covers psychopathology, pervasiveness, func-
tional status and comorbidity.
A similar spectrum of psychopathology and related
impairments can be examined using the Brown ADD Di-
agnostic Form (Brown ADD-DF, 1996). The above- men-
tioned Brown ADD-RS together with a variety of other
instruments is part of this comprehensive assessment
procedure dealing with different history parameters,
impact on social functioning, comorbidity, IQ, sleep etc.
In contrast, the Adult ADHD Investigator Symptom
Rating Scale (AAISRS, Adler et al. 2003b) is relatively
easy to use regarding administration and interpretation
of the results. The main target is the ascertainment and
quantification of the eighteen DSM-IV items. Normative
data and psychometric properties are unknown so far.
Assessing comorbid conditions
As mentioned above,“pure” ADHD in adulthood occurs
not frequently. The differentiated diagnostic evaluation
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Table 3 Interviews for diagnostic use in adult ADHD

Interview, author Items Normative data Administration References

Factors + Syndromes psychometric Cut-off
Properties Language

Wender-Reimherr 28 iItems, American and German 30 min, Wender (1995)

Interview WRAADDS 7 domains and syndromes populations factor structure Cut-off according to Rösler et al. (2006)
0–2 item scale evaluated, different aspects Utah criteria,
0–4 syndrome graduation of reliability and validity 1 total + 7 domain ratings
determined Eng, Ger

Conners’Adult ADHD Part I: History Used in multiple scientific 90 min, Epstein et al. (2001)
Diagnostic Interview Part II: 18 DSM-IV items research, psychometric data DSM-IV rules impairment
for DSM-IV and criteria B-E, adult not published so far score
CAADID and childhood symptoms Eng

Adult Interview 18 DSM-IV items, current No Norms or psychometric 90 min Barkley and Murphy (1998)
Barkley & Murphy and childhood symptoms, properties DSM-IV, functional impairment
10 items social functioning score
childhood and current status, Eng, Ger
16 additional items, ODD + CD
symptoms, antisocial personality
disorder (ASP), history items,
mood disorder comorbidity

Brown ADD Scale Multirater 18 DSM-IV items, Population norms 90 min Brown T (2005)
Diagnostic Form items for clinical history, impact DSM-IV, different
Brown ADD-DF on work, leisure, school, peer psychopathological and
interaction and self image. function scores
History of family, health and Eng
sleep, comorbidity, observer
information, IQ scale

Adult ADHD 18 DSM-IV items, 0–3 scale No normative data and 15 min Adler et al. (2003b)
Investigator Symptom psychometric properties DSM-IV
Rating Scale published so far, interview Eng
AAISRS used in pharmacological
Adler et al. trials and other research

Eng English; Ger German; Hisp Hispanic; Fre French; SRF Self Report Form; Rel Reliability; SD Standard Deviation; ODD Oppositional Defiant Disorder; CD Conduct Disorder;
Min Minutes

of comorbid disorders is therefore very useful. The as-
sessment of comorbid disorders is a substantial part of
the Brown ADD-DF (Brown 2005) and the AI by Barkley
and Murphy (1998). The CAADID offers a screening
procedure for the main comorbid disorders. In clinical
treatment trials, comorbidity is often assessed using the
SCID I and II interview (Wittchen et al. 1997). To address
comorbidity on a dimensional level one might adminis-
ter the Hamilton Anxiety Scale, the Hamilton Depres-
sion Scale or the Beck Depression Inventory. These
scales as well as the Symptom Checklist-90-R have been
used in research programmes with ADHD patients
(Chang and Chuang 2000, Ziegler et al. 2003).
Other rating instruments
The change in hyperactivity from childhood to adult-
hood is the main focus of the Internal Restless Scale
(IRS, Weyandt et al. 2003). The concept of the IRS is
based on the assumption that in adults with ADHD in-
ternal restlessness has replaced the overt hypermotility
in children. The scale is a self-report instrument con-
taining 24 items each ranging from 1 to 7 on a Likert
scale. A factor analysis displayed a four-factor solution.
Measures of retest reliability and convergent validity
demonstrated sufficient values. No gender differences
could be detected.
Since there is substantial evidence that adults suffer-
ing from ADHD are impaired in multiple domains such
as academic and occupational achievement, leisure ac-
tivities, marital and parental affairs, there is growing in-
terest in scales measuring such functional deficits
(Weiss 2005). Other functional problems are a high
prevalence of accidents in different life situations and le-
gal problems caused by problematic driving behaviours
like speeding (Woodward et al. 2000, Grützmacher 2002,
Barkley et al. 2002, 2004, Faraone 2005). High rates of ar-
rests and convictions must be considered as an adult
consequence of ADHD (Rösler et al. 2004b, Faraone
2005). The functional aspects of ADHD have received
more and more attention, because questions concerning
the clinical relevance of the disease and the need for
treatment can be much better answered if the functional
status is evaluated. Both the AI by Barkley and Murphy
(1998) and the Brown ADD scale diagnostic form (2005)
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contain functional measures for use in ADHD diagnos-
tic processes. Based on the report of an informant, the
Childhood School Performance Scale (CSPS) by Barkley
and Murphy (1998) examines retrospectively the conse-
quences of ADHD symptoms on different areas of
school activity. The Work Performance Rating Scale
(WPRS-SRF) by Barkley and Murphy (1998) evaluates
the impact of the DSM-IV criteria in ten areas of work
activity. A generally accepted scale covering the most
important types of functional impairments in adults
with ADHD is not available so far. The GAF of DSM-IV
offers a global index of functional impairment, but by
definition cannot give more detailed information. In
general psychiatry the Sheehan Disability Scale (SDS,
Sheehan 1983) has often been used in epidemiological
and clinical research. The SDS is a 3-item self-report
scale measuring the severity of disability in the domains
of work, family life and social activities. The psychomet-
ric properties of the scale have been determined (Leon
et al. 1992). Adler et al. (2004) used the SDS as an out-
come parameter during a two year ADHD treatment
with atomoxetine and found a significant reduction of
the functional impairments.
Similar to other chronic disorders, adults suffering
from ADHD are at risk of developing negative life out-
comes. On the one hand ADHD adults display low self-
esteem, poor interpersonal relationships and academic
underachievement. On the other hand they seem to have
an enhanced facility for problem solving. Little is known
about the impact on Quality of Life (QoL) of these indi-
viduals. Measures of QoL can be a separate meaningful
tool for the assessment of the chronic course of adult
ADHD. A new ADHD related QoL scale has been de-
signed by Landgraf (2005). A publication with its norms
and psychometric evaluations is not available so far. A
useful alternative are the WHO Quality of Life Scales
(WHOQOL-100 + WHOQOL-BREV, 1998) which are
available in many languages.
Discussion
Rating scales are a cost-effective and useful tool for as-
sessing ADHD psychopathology and its impact on social
functioning. There are some carefully designed rating
instruments with acceptable psychometric properties,
which can easily be administered. With the help of these
scales, large amounts of information can be obtained
which provide sufficient material to make a valid diag-
nosis as well as to monitor treatment strategies in ADHD
patients. All the rating scales mentioned above generate
quantitative psychopathological scores; they can be ad-
ministered repeatedly with time to monitor treatment
response, although the sensitivity for change has not
been examined for the most scales. However, a clear
preference for one instrument in helping to make a di-
agnosis or monitoring the course of ADHD in the sense
of a golden standard has not been established so far.
It is possible to differentiate instruments for the ret-
I/9
rospective examination of childhood ADHD symptoms
from those rating scales designed to evaluate current
ADHD psychopathology. Regarding methodology, self-
rating scales and observer rating scales can be distin-
guished. Compared with clinician-administered instru-
ments, self-report scales are economic in terms of the
physician’s time. However, patient’s self-ratings might
not always be reliable and valid. Some patients might
have difficulties recalling childhood symptoms or inter-
preting their current symptoms with the consequence of
over- and underestimation of the psychopathology.
Thus it might be useful to collect additional information
from informants. However, as with patients, third party
information can be influenced by clouded recall or bi-
ased recognition in terms of the frequency and severity
of symptoms (Murphy and Schachar 2000, Mannuzza
et al. 2002). In addition the general limitations concern-
ing the use of ratings scales must be considered, e. g. halo
effect, severity error etc. (Conners 1998, Stieglitz und
Freyberger 2001).
It is difficult to decide which kind of scale should be
given preference. We compared the ADHD-SR and the
ADHD-OR measuring DSM-IV oriented ADHD psy-
chopathology and found high correlations between the
corresponding scores of each scale (total, inattention
and hyperactivity/impulsivity). This indicates a high
correspondence of self and expert ratings (Rösler et al.
2004a). In other psychiatric disorders, e. g. schizophre-
nia, self report and other report psychopathology can
show a clearly weaker correlation (Stieglitz and Frey-
berger 2001). Therefore, clinicians should gather both
self-report and other-report ratings and use them as two
different information sources with their own value.
The main psychopathological focus of the above re-
viewed rating scales is DSM-IV with its eighteen symp-
toms of inattention, hyperactivity and impulsivity. All
scales do collect sufficient data to establish one of the
three DSM-IV ADHD diagnoses when using a categori-
cal approach for the assertion of the diagnostic criteria.
The two additional DSM-IV diagnoses (“ADHD residual
type” and “ADHD not otherwise specified”) cannot be
made in this way because there are no clear-cut diag-
nostic criteria.
The ASRS Screener plays a special role. Containing
six diagnostic symptoms, it takes only a few minutes to
complete and therefore is ideal for screening proce-
dures.
No instrument is designed to give ICD-10 diagnoses
(WHO 1997): These are the simple disorder of attention
and activity (SDAA, F90.0) and the hyperkinetic con-
duct disorder (HCD, F90.1). The clinical version of the
ICD-10 uses no operational criteria for the diagnosis
and is based only on descriptions of the psychopatho-
logical picture. However the research version of the ICD-
10 has adopted the eighteen DSM-IV criteria. Thus it
should be possible to diagnose the SDAA (F90.0, ICD-
10-RC)” with the instruments used for DSM-IV diag-
noses, because SDAA and ADHD combined type are
nearly equal. But the second ICD-10-RC diagnosis HCD
03_11_Rösler_EAPCN_S_1001 06.09.2006 12:22 Uhr Seite 10
I/10
(F90.1) cannot be made in this way, because the conduct
symptoms are not assessed in any of the mentioned in-
struments.
Few scales offer further information about different
symptom domains. The CAARS measures emotional la-
bility and self-concept problems. The Brown ADD-RS
contains scores for organizing and activating for work,
sustaining energy and effort, managing affective inter-
ference and working memory.
With the exception of the AAISRS, diagnostic inter-
views need more time for their completion when com-
pared with rating scales. Thus, these instruments have
their place preferentially in scientific studies where the
control of the investigators’ variance and the careful in-
clusion and exclusion according to DSM-IV of thor-
oughly scrutinized patients is essential. In pharmaco-
logical studies about the efficacy of new treatments,
diagnostic interviews are in almost all cases part of the
study protocol.
The AI and Brown ADD-DF examine the most fre-
quent comorbid disorders. In addition to their func-
tional measures, both diagnostic procedures offer the
most comprehensive patient evaluation when compared
with the other scales.
The WRI differs from the other interviews in so far as
the underlying diagnostic concept refers to the Utah cri-
teria (Wender 1995). This is an alternative system to di-
agnose adults with ADHD. The items encompass overt
behaviour symptoms as well as self-experience adult
psychopathology. An advantage of the WRI could be the
extended spectrum of adult psychopathology with
seven instead of the three DSM-IV symptom areas. The
WRI items reflecting emotional dysregulation were
shown to improve when the patients were treated with
atomoxetine, thus indicating that not only inattention
and hyperactivity/impulsivity can be responsive to
ADHD treatments (Reimherr et al. 2005). On the basis of
the WRI, DSM-IV diagnoses cannot be made. It is evi-
dent that patients with predominantly inattentive symp-
toms as well as those with predominantly hyperactiv-
ity/impulsivity according to DSM-IV are excluded by
the Utah concept. Our research on adult ADHD diag-
noses with DSM-IV or alternatively with the Utah crite-
ria has revealed that the Utah criteria are indeed more
restrictive: When using the Utah instead of the DSM cri-
teria, the reduction of the number of persons classified
as suffering from ADHD in a population referred to our
ADHD outpatient unit was about 20 % (unpublished
data). Considerable amount of overlap, however, exists
between the WRI ADHD diagnosis and the ADHD com-
bined type according to DSM-IV.
Future developments should focus on functional im-
pairments and quality of life in adults with ADHD. In
this field of research no generally accepted instruments
are available yet. Notwithstanding, the development of
future treatment measures of functional disabilities and
the impact on quality of life will have growing relevance.
Examples of rating scales with a more targeted diag-
nostic spectrum are gender-specific scales, trying to
find differences in female and male ADHD (Mannuzza
& Gittelman 1984, Nadeau & Quinn 2005, Quinn 2005),
and scales that focus on a particular symptom domain,
e. g. the IRS (Weyandt et al. 2003). Not much is known
about the research with such instruments.
In summary, there are an increasing number of diag-
nostic instruments which support the clinician in estab-
lishing a reliable and valid diagnosis of ADHD and in as-
sessing the course of the disorder. Nevertheless, adult
ADHD remains a clinical diagnosis and no instrument
can replace an intensive clinical examination by a clini-
cian with expertise in the area of ADHD.
References
1. Adler L, Kessler R, Spencer T (2003a) Adult Self Report Scale,
ASRS-V1.1 Screener. World Health Organization, New York
2. Adler L, Spencer T, Biederman J (2003b) Adult ADHD Investiga-
tor Symptom Rating Scale. New York University School of Medi-
cine, New York
3. Adler L, Kelsey D, Dietrich AP, Reimherr FW, Sangal BR et al.
(2004) Quality-of-life assessment in Atomoxetine-treated adult
ADHD patients. APA, New York
4. American Psychiatric Association (1994) Diagnostic and Statis-
tical Manual of Mental Disorders, 4th edn. APA, Washington DC
5. Angermeyer MC, Kilian R, Matschinger H (2000) WHOQOL-100
und WHOQOL–BREF. Hogrefe, Göttingen
6. Barkley RA (2002) Major life activity and health outcomes asso-
ciated with attention-deficit/hyperactivity disorder. J Clin Psy-
chiat 63 (Suppl 12):10–15
7. Barkley RA, Murphy KR (1998) Attention-deficit hyperactivity
disorder. A clinical workbook Guilford, New York
8. Barkley RA, Fischer M, Smallish L, Fletcher K (2004) Young adult
follow-up of hyperactive children: Antisocial activities and drug
use. J Child Psychol Psychiat 45:195–211
9. Biederman J (2005) Psychiatric and functional outcome of ado-
lescent females with ADHD: A large, controlled, five-year longi-
tudinal follow-up study. APA, Atlanta
10. Brown TE (1996) Brown Attention-Deficit Disorder Scales for
Adolescents and Adults.Manual.The Psychological Corporation,
San Antonio
11. Chang HL, Chuang HY (2000) Adolescent hyperactivity and gen-
eral psychopathology. Psychiatry Clin Neurosci 54:139–146
12. Conners CK (1996) Rating scales in attention-deficit/hyperactiv-
ity disorder: Use in assessment and treatment monitoring. J Clin
Psychiat 59 (Suppl 7):24–30
13. Conners CK, Ehrhard D, Sparrow D (1999) CAARS Adult ADHD
Rating Scales. MHS, New York
14. DuPaul G, Power T,Anastopoulos A, Reid R (1998) ADHD Rating
Scale. IV: Checklist, norms, and clinical interpretation. Guilford,
New York
15. Epstein J, Johnson DE, Conners CK (2001) Conners’Adult ADHD
Diagnostic Interview for DSM-IV (CAADID). MHS, New York
16. Faraone S (2005a) Functional impairments in adult ADHD: Im-
plications for diagnosis. APA, Atlanta
17. Faraone S (2005b) The scientific foundation for understanding
attention-deficit/hyperactivity disorder as a valid psychiatric
disorder. Eur Child Adolesc Psychiat 14:1–10
18. Faraone S, Biederman J (1998) Neurobiology of attention deficit-
/hyperactivity disorder. Biol Psychiatry 44:951–958
19. Fossatti A, Ceglie A, Aquarini E, Donati D, Donini M, Novella L,
Maffei C (2001) The retrospective assessment of childhood at-
tention deficit hyperactivity disorder in adults: reliability and
validity of the Italian version of the Wender Utah Rating Scale.
Compr Psychiat 42:326–336
20. Groß J, Blocher D, Trott GE, Rösler M (1999) Assessment of the
attention-deficit/hyperactivity disorder in adults. Nervenarzt 70:
20–25
03_11_Rösler_EAPCN_S_1001 06.09.2006 12:22 Uhr Seite 11
21. Grützmacher H (2001) Unfallgefährdung bei Aufmerksamkeits-
und Hyperaktivitätsstörung. Deutsches Ärzteblatt 98:1898–1900
22. Heiligenstein E, Conyers LM, Berns AR, Smith MA (1998) Pre-
liminary normative data on DSM-IV attention deficit hyperac-
tivity disorder in college students. J Am Coll Health 46:185–188
23. Kessler RC (2004) Prevalence of Adult ADHD in the United
States: Results from the National Comorbidity Survey Replica-
tion (NCS-R) proceedings summary S 0.6. APA, New York
24. Kessler RC, Adler LA, Barkley R et al. (2005a) Patterns and pre-
dictors of attention-deficit/hyperactivity disorder persistence
into adulthood: results from the National Comorbidity Survey
replication. Biol Psychiatry 57:1442–1451
25. Kessler RC, Adler L, Ames M et al. (2005b) The World Health Or-
ganisation adult ADHD self-report scale (ASRS). A short screen-
ing scale for use in the general population. Psychol Medicine 35:
245–256
26. Landgraf J (2005) Measuring Quality-of-Live in adults with
ADHD. APA Atlanta
27. Leon AC, Shear K, Potera L et al. (1992) Assessing impairment in
patients with panic disorder: The Sheehan Disability Scale. Soc
Psychiatry Psychiatr Epidemiol 27:78–82
28. Mannuzza S, Gittelman T (1984) The adolescent outcome of hy-
peractive girls. Psychiatry Res 13:19–29
29. Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M (1993)
Adult outcome of hyperactive boys: educational achievement,
occupational rank, and psychiatric status. Arch Gen Psychiat
50:565–576
30. Mannuzza S, Klein RG, Klein DF, Bessler A, Shrout P (2002) Ac-
curacy of adult recall of childhood attention deficit hyperactiv-
ity disorder. Am J Psychiat 158:1882–1888
31. McGough JJ, Barkley RA (2004) Diagnostic controversies in
adult attention deficit hyperactivity disorder. Am J Psychiat
161:1948–1956
32. Michelson D, Adler D, Spencer T et al. (2003) Atomoxetine in
adults with ADHD. Two randomized, placebo-controlled studies.
Biol Psychiatry 53:112–120
33. Milberger S, Biederman J, Faraone SV, Murphy J, Tsuang MT
(1995): Attention deficit hyperactivity disorder and comorbid
disorders: Issues of overlapping symptoms. Am J Psychiat 152:
1793–1799
34. Murphy P, Schachar R (2000) Use of self-ratings in the assess-
ment of symptoms of attention deficit hyperactivity disorder in
adults. Am J Psychiatry 157:1156–1159
35. Murphy K, Barkley RA (1996) Prevalence of DSM-IV symptoms
of ADHD in adult licensed drivers: Implications for clinical di-
agnosis. J Attention Disorders 1:147–161
36. Murphy KR, Adler LA (2004) Assessing attention-deficit/hyper-
activity disorders in adults: Focus on rating scales. J Clin Psychi-
atry 65 (Suppl 3):12–17
37. Nadeau KG, Quinn P (2005) ADHD Self-Rating Scale for Women.
Download www.adhs.ch
38. Pliszka S (1998) Comorbidity of attention deficit hyperactivity
disorder with psychiatric disorder: an overview. J Clin Psychiat
59 (Suppl 7):50–58
39. Quinn PQ (2005) Treating adolescent girls and women with
ADHD: Gender-specific issues. J Clin Psychol 60:579–587
40. Reimherr F (2004) The Wender Reimherr Interview. Personal
Communication
41. Reimherr FW, Marchant BK, Strong RE,Adler L, Spencer TJ,West
SA, Soni P (2005) Emotional dysregulation in adult ADHD and
response to atomoxetine. Biol Psychiatry 58:125–131
42. Retz-Junginger P, Retz W, Blocher D et al. (2002) Wender Utah
rating scale. The short-version for the assessment of the atten-
tion-deficit hyperactivity disorder (in German). Nervenarzt 73:
830–838
I/11
43. Retz-Junginger P, Retz W, Blocher D, Stieglitz RD, Supprian T,
Wender PH, Rösler M (2003) Reliability and validity of the Ger-
man short version of the Wender-Utah Rating Scale for the ret-
rospective assessment of attention-deficit/hyperactivity disor-
der (in German). Nervenarzt 74:987–993
44. Rodriguez Jiminez CR, Ponce AG, Monasor Sanchez R, Jimenez
Gimenez M, Perez Rojo JA, Rubio Valladolid G, Jimenes Arriero
MNM, Palomo Arvarez T (2001) Validation in the adult Spanish
population of the Wender Utah Rating Scale for the retrospective
evaluation in adults of attention-deficit/hyperactivity disorder
in childhood. Rev Neurol 33:138–1440
45. Rösler M, Retz W, Retz-Junginger P et al. (2004a) Tools for the di-
agnosis of attention-deficit/hyperactivity disorder in adults.
Self-rating behaviour questionnaire and diagnostic checklist
(German). Nervenarzt 75:888–895
46. Rösler M, Retz W, Retz-Junginger P et al. (2004b) Prevalence of
attention deficit hyperactivity disorder in male young adult
prison inmates. Eur Arch Psychiat Clin Neurosci 254:365–371
47. Rösler M, Retz-Junginger P, Stieglitz R (eds) (2006) Scales for the
diagnosis of ADHD in adults. German title: Instrumente zur Di-
agnostik der ADHS bei Erwachsenen. Hogrefe, Göttingen (in
preparation)
48. Sheehan DV (1983) The anxiety disease. Scribner, New York
49. Stein MA, Sandoval R, Szunowski E, Roizen N, Reinecke MA,
Blondis TA, Klein Z (1995) Psychometric characteristics of the
Wender Utah Rating Scale (WURS)): reliability and factor struc-
ture for men and women. Psychopharmacol Bull 31:425–433
50. Stieglitz RD, Freyberger H (2001) Selbstbeurteilungsverfahren.
In: Stieglitz RD, Baumann U, Freyberger HJ (eds) Psychodiag-
nostik in Klinischer Psychologie, Psychiatrie, Psychotherapie.
Thieme, Stuttgart
51. Ward MF, Wender PH, Reimherr FW (1993) The Wender Utah
Rating Scale: An aid in the retrospective diagnosis of childhood
attention deficit hyperactivity disorder. Am J Psychiatry 150:
885–890
52. Weiss G, Hechtman LT, Milroy T, Perlman (1985) Psychiatric sta-
tus of hyperactives as adults: a controlled prospective 15-year
follow-up of 63 hyperactive children. J Am Acad Child Psychiat
24:211–220
53. Weiss M (2005) Functional impairment in adults with ADHD.
APA, Atlanta
54. Wender PH (1995): Attention-deficit hyperactivity disorder in
adults. Oxford University Press, Oxford New York
55. Wender P (2004) Wender Reimherr Interview. Personal Commu-
nication
56. Weyandt L, Iwaszuk W, Fulton K, Ollerton M, Beatty N, Fouts H,
Schepman S, Greenlaw C (2003) The Internal Restlessness Scale:
Performance of college students with and without ADHDJ Learn
Disab 36:382–389
57. Wittchen HU, Wunderlich U, Gruschwitz S, Zaudig M (1997)
Strukturiertes Klinisches Interview für DSM-IV (SKID).
Hogrefe, Göttingen
58. Woodward L, Fergusson D, Horwood J (2000) Driving outcomes
of young people with attentional difficulties in adolescence. J Am
Acad Child Adolesc Psychiatry 39:627–634
59. World Health Organization (1993) Tenth Revision of the Inter-
national Classification of Diseases, Chapter V: Mental and Be-
havioural Disorders: Diagnostic Criteria for Research. Huber,
Bern
60. Ziegler E, Blocher D, Groß J, Rösler M (2003) Assessment of at-
tention-deficit hyperactivity disorder in prison inmates (Ger-
man). Recht and Psychiatrie 21:17–21