How do I use the Adult ADHD Self-Report Questionnaire (ASRS) to diagnose Attention Deficit Hyperactivity Disorder (ADHD)?

Using the Adult ADHD Self-Report Scale (ASRS) to Diagnose ADHD

The Adult ADHD Self-Report Scale (ASRS-V1.1) is an effective screening tool for adult ADHD with high sensitivity and moderate specificity, and should be used as the first step in a diagnostic process, followed by comprehensive clinical evaluation to confirm the diagnosis.

Understanding the ASRS Screening Tool

The ASRS-V1.1 is a validated 6-question screening tool developed by the World Health Organization that helps identify adults who may have ADHD. Here's how to use it properly:

Step 1: Administer the ASRS Screener

• Have the patient complete Part A of the ASRS-V1.1, which contains 6 questions about frequency of ADHD symptoms
• The patient should indicate how often they experience each symptom (never, rarely, sometimes, often, or very often)
• The screener takes approximately 1 minute to complete (average 54.3 seconds) 1
• A screen is considered positive when the patient checks "often" or "very often" for 4 or more of the 6 questions 2

Step 2: Interpret the Screening Results

• The 6-question ASRS screener has demonstrated:
  • High sensitivity (68.7%)
  • Excellent specificity (99.5%)
  • Strong overall classification accuracy (97.9%)
  • Good reliability (kappa = 0.76) 3
• A positive screen warrants further evaluation but is not diagnostic by itself
• A negative screen is highly reliable for ruling out ADHD (negative predictive value of 1.0) 1

Moving from Screening to Diagnosis

Step 3: Complete the Full Clinical Assessment

If the ASRS screener is positive:

1. Administer the full ASRS questionnaire (Part B)

   • The complete ASRS contains 18 questions mapping to DSM-5 criteria
   • This provides more detailed information about specific symptom domains

2. Obtain collateral information

   • Have someone who knows the patient well (spouse, parent, close friend) complete the ASRS with the patient in mind 2
   • Adults with ADHD tend to underreport their symptoms (46% sensitivity when self-reporting) 4
   • Informant reports provide valuable additional information about symptoms and impairment 5

3. Assess functional impairment

   • Use a functional impairment scale such as the Weiss Functional Impairment Rating Scale-Self (WFIRS-S) 2
   • Evaluate impairment across multiple domains: work, home management, social relationships, etc.

4. Document symptom onset before age 12

   • To meet DSM-5 criteria, symptoms must have been present before age 12 2
   • Review school records, obtain parent reports, or other historical documentation

Step 4: Rule Out Alternative Explanations

• Screen for comorbid conditions that may mimic or complicate ADHD 2:

  • Mood disorders (depression, bipolar disorder)
  • Anxiety disorders
  • Substance use disorders
  • Learning disabilities
  • Sleep disorders
  • Trauma/PTSD

• Note that the ASRS alone cannot differentiate ADHD from other psychiatric disorders, as patients with anxiety and depression may also score in the clinical range 6

Important Clinical Considerations

Diagnostic Criteria Verification

To confirm ADHD diagnosis after positive screening, verify that the patient meets full DSM-5 criteria:

• 5 or more symptoms of inattention and/or hyperactivity-impulsivity for at least 6 months
• Symptoms present in multiple settings
• Clear evidence of functional impairment
• Symptoms not better explained by another mental disorder 2

Special Considerations for Different Presentations

• Adults are more likely to present with inattentive symptoms than hyperactive/impulsive symptoms 2
• Women may present differently than men, with less obvious hyperactivity
• Symptoms may manifest differently in adults compared to children (e.g., inner restlessness rather than overt hyperactivity)

Common Pitfalls to Avoid

1. Relying solely on self-report questionnaires

   • Adults with ADHD tend to underestimate their own impairments 4
   • The ASRS is a screening tool, not a diagnostic instrument

2. Failing to assess for comorbidities

   • The majority of adults with ADHD have at least one comorbid condition 2
   • Substance use disorders, anxiety, and depression can complicate diagnosis

3. Not establishing childhood onset

   • Symptoms must have been present before age 12 to meet diagnostic criteria 2
   • This may require collateral history from parents or school records

4. Overlooking functional impairment

   • ADHD diagnosis requires evidence that symptoms interfere with functioning
   • Assessment should include impact on work, relationships, and daily activities

By following this structured approach using the ASRS as an initial screening tool followed by comprehensive clinical assessment, clinicians can effectively identify adults with ADHD and distinguish it from other conditions with similar presentations.