What is the standard procedure for scoring and interpreting ADHD questionnaires, such as the Conners Adult ADHD Rating Scales (CAARS) or the Vanderbilt Assessment Scale, for diagnosis and treatment?

ADHD Questionnaire Scoring and Interpretation

Behavior rating scales like the Conners Adult ADHD Rating Scales (CAARS) and Vanderbilt Assessment Scale should be scored according to their standardized protocols and interpreted as part of a comprehensive multi-informant evaluation—not as standalone diagnostic tools—with scores used to document symptom presence across multiple settings as required by DSM-5 criteria. 1, 2

Standard Scoring Procedures

Vanderbilt Assessment Scale (Ages 6-12)

• Complete both parent and teacher versions to gather information across home and school settings, as the American Academy of Pediatrics specifically recommends this tool for elementary and middle school children 1
• Score each item on the provided Likert scale (typically 0-3: never, occasionally, often, very often) 1
• Calculate subscale totals for inattention symptoms (9 items) and hyperactivity-impulsivity symptoms (9 items) 1
• A symptom is considered present when rated as "often" or "very often" (scores of 2 or 3) 1
• Document performance and comorbidity screens included in the scale (oppositional defiant disorder, conduct disorder, anxiety, depression) 1

Conners Adult ADHD Rating Scales (CAARS)

• Use age-appropriate normative data when scoring, as the scale has been validated for different age groups 1
• Convert raw scores to T-scores using the standardized tables provided in the manual 3
• T-scores ≥65 (1.5 standard deviations above the mean) typically indicate clinically significant symptoms 3
• The CAARS demonstrates convergent validity with other ADHD measures (r = .71) 3

Critical Interpretation Framework

These Scales Are NOT Diagnostic Tests

• Rating scales serve to systematically collect symptom information—they do not diagnose ADHD by themselves 4, 5, 6
• The American Academy of Pediatrics emphasizes that ADHD remains a clinical diagnosis requiring comprehensive evaluation beyond questionnaire scores 4, 6
• No single test or scale is diagnostically definitive for ADHD 5

Required Components Beyond Questionnaire Scores

To make an ADHD diagnosis, you must document:

1. Symptom threshold met: At least 6 symptoms of inattention and/or hyperactivity-impulsivity present for ≥6 months 2

2. Multiple setting impairment: Functional impairment documented in more than one major setting (home, school, work, social) using information from parents, teachers, and other observers 4, 1, 2

3. Age of onset: Symptoms present before age 12 years (obtain collateral information from parents or siblings for adults) 2, 6

4. Alternative causes ruled out: Exclude other medical, psychiatric, or situational explanations through clinical interview and examination 4, 2, 5

5. Comorbidity screening: Systematically assess for anxiety, depression, oppositional defiant disorder, conduct disorder, learning disabilities, and sleep disorders, as these commonly co-occur and alter treatment approach 1, 2, 7

Age-Specific Considerations

Preschool Children (Ages 4-5)

• Use preschool-age normative data when available on rating scales 1
• Evidence is insufficient for definitive diagnosis at this age; consider parent training in behavior management before assigning diagnosis 7

School-Age Children (Ages 6-11)

• The Vanderbilt scales are specifically designed and recommended by the American Academy of Pediatrics for this age group 1
• Obtain both parent and teacher ratings to document cross-setting impairment 1

Adolescents (Ages 12-18)

• Gather information from multiple teachers when adolescents have several instructors 1
• Screen carefully for substance abuse, depression, and anxiety as alternative or comorbid diagnoses 2

Adults

• Use the CAARS with appropriate adult normative data 1
• Obtain collateral information about childhood symptoms from parents or siblings to confirm age of onset before 12 years 2, 6
• The clinician-administered interview remains the cornerstone of adult ADHD diagnosis 6

Common Pitfalls to Avoid

• Relying solely on questionnaire scores without clinical interview and multi-informant data 4, 5, 6
• Failing to gather information from both home and school settings 1, 2
• Not screening for comorbid conditions that may complicate treatment 1, 2, 7
• Underdiagnosing girls who present with predominantly inattentive symptoms rather than hyperactive symptoms 7
• Using rating scales without age-appropriate normative data 1
• Ignoring the need to document functional impairment beyond symptom counts 2

Validity Concerns in Scoring

• Be aware that ADHD symptoms can be easily feigned or exaggerated, particularly in college students and young adults seeking accommodations 8
• The Conners scales include validity indices to detect exaggerated symptom reporting (Exaggeration Index demonstrates 97% specificity) 8
• Consider symptom validity testing when clinical presentation seems inconsistent or implausible 8

Integration with Treatment Decisions

• Once diagnosis is established, use the same rating scales to monitor treatment response over time 4
• For children ages 6-11, first-line treatment includes FDA-approved medications preferably combined with behavioral therapy 1
• For adolescents ages 12-18, first-line treatment includes FDA-approved medications with the adolescent's assent, which may be combined with behavioral therapy 1
• Titrate medication doses to achieve maximum benefit with minimum adverse effects, using rating scales to track symptom improvement 1