What does an ADHD ASRS v score of 28 indicate, and how should it be managed?

Interpreting ADHD ASRS v1.1 Score of 28

A score of 28 on the Adult ADHD Self-Report Scale (ASRS v1.1) strongly indicates the presence of ADHD and warrants further clinical evaluation and appropriate treatment.

Understanding the ASRS Score

The ASRS v1.1 is a validated screening tool for adult ADHD with high sensitivity and specificity. The 18-question version has the following interpretation:

• A score of 28 falls well above established clinical thresholds
• Research indicates scores above 23-26 suggest a high likelihood of ADHD 1
• The ASRS has shown excellent psychometric properties with sensitivity of 96.7% and specificity of 91.1% when properly scored 2

Diagnostic Confirmation

While the ASRS score strongly suggests ADHD, proper diagnosis requires:

1. Verification that DSM-5 criteria are met
2. Documentation of symptoms and impairment in more than one major setting (social, academic, or occupational) 3
3. Ruling out alternative causes for symptoms 3
4. Confirming that symptoms have been present before age 12 4

ADHD Presentation Assessment

Based on the ASRS responses, determine which ADHD presentation is most likely:

• Predominantly inattentive type: 5+ symptoms of inattention, <5 symptoms of hyperactivity-impulsivity 3
• Predominantly hyperactive-impulsive type: 5+ symptoms of hyperactivity-impulsivity, <5 symptoms of inattention 3
• Combined type: 5+ symptoms of inattention AND 5+ symptoms of hyperactivity-impulsivity 3

Management Approach

Medication Management

For adults with confirmed ADHD:

1. First-line pharmacotherapy:

   • FDA-approved stimulants (methylphenidate or amphetamine derivatives)
   • Start with low doses and titrate weekly to achieve maximum benefit with minimum side effects 4

2. Alternative medications if stimulants are contraindicated or ineffective:

   • Atomoxetine
   • Extended-release guanfacine
   • Extended-release clonidine 4

3. Dose titration:

   • For methylphenidate: 5-10 mg weekly increments (max 60 mg daily)
   • For amphetamines: 2.5-5 mg weekly increments (max 40 mg daily) 4

Behavioral Interventions

Evidence-based behavioral interventions should be implemented alongside medication:

• Cognitive-behavioral therapy focused on organizational skills
• Time management training
• Problem-solving strategies
• Emotional regulation techniques 4

Monitoring and Follow-up

1. Initial phase:

   • Weekly contact during medication titration
   • Monitor for side effects: insomnia, appetite changes, headaches, weight changes

2. Maintenance phase:

   • Monthly appointments until symptoms are well-controlled
   • Regular assessment of functional impairment using validated tools like the Weiss Functional Impairment Rating Scale 3
   • Screen for comorbid conditions (anxiety, depression, substance use disorders)

Common Pitfalls to Avoid

• Inadequate dose adjustment: Systematic titration is essential rather than assuming treatment failure 4
• Overlooking timing of medication: Concentration problems may occur when medication levels are suboptimal 4
• Focusing only on medication: Ensure behavioral interventions are also implemented 4
• Premature treatment discontinuation: Increases risk for various negative outcomes including substance use disorders, depression, and academic/occupational underachievement 4

Special Considerations

For adults with ADHD who are pregnant or planning pregnancy:

• Develop a management plan involving the patient and their support network
• Address factors that may worsen functioning in the perinatal period
• Consider risks and benefits of medication continuation during pregnancy 3

Remember that ADHD is a chronic condition requiring ongoing care. Following principles of the chronic care model can improve outcomes and quality of life for adults with ADHD.