Stimulant Therapy for Moderately Elevated Conners Scores
Stimulant therapy is not indicated based solely on moderately elevated Conners self-assessment scores—you must first confirm a formal DSM-IV/ICD-10 diagnosis of ADHD with documented moderate-to-severe functional impairment in at least two different settings before initiating treatment. 1
Diagnostic Requirements Before Treatment
The Conners Adult ADHD Rating Scale (CAARS) is a validated screening and monitoring tool, but elevated scores alone do not justify stimulant therapy. 2, 3 You must complete the following before prescribing:
Obtain a comprehensive psychiatric and medical history including collateral information from at least two sources in different settings (workplace/home for adults, school/home for children) to verify symptoms across contexts 1
Document DSM-IV or ICD-10 criteria for ADHD with specific attention to symptom onset before age 7, chronicity, and pervasiveness across settings 1
Assess functional impairment severity in academic/occupational, social, and family domains—only moderate to severe impairment in at least two settings qualifies for stimulant treatment 1
Rule out alternative explanations including poor adherence to other treatments, comorbid psychiatric conditions masquerading as ADHD, substance use, or medical conditions that could explain symptoms 4
Important Caveats About Self-Report Measures
Self-report scales like the CAARS have significant limitations that make them insufficient for diagnosis:
Self-reports show good correlation with investigator ratings (rs = .65) but investigator-rated baseline scores are stronger predictors of treatment outcome than self-report scores 5, 3
The CAARS is vulnerable to symptom exaggeration, with studies showing 30-46% of instructed simulators can produce falsely elevated scores even with embedded validity indices 6
Self-report measures are most useful for monitoring treatment response in already-diagnosed patients on stable stimulant doses, not for establishing initial diagnosis 5
Treatment Algorithm When Diagnosis is Confirmed
If formal ADHD diagnosis with moderate-to-severe impairment is established:
First-line treatment is stimulant medication (methylphenidate or amphetamines) with 70-80% response rates and the strongest evidence base from over 161 randomized controlled trials 1, 7
Start with methylphenidate 5 mg or dextroamphetamine 2.5 mg twice daily after breakfast and lunch, titrating weekly by 5-10 mg (MPH) or 2.5-5 mg (DEX/AMP) based on response 1
Maximum recommended doses are 60 mg/day for methylphenidate and 40 mg/day for amphetamines per PDR guidelines, though expert consensus allows higher doses in select cases 1
Obtain teacher/workplace ratings using validated, age- and sex-normed instruments at baseline and after treatment to objectively document response 1
When Stimulants Are Contraindicated
Consider non-stimulant alternatives if:
Active substance abuse is present—use atomoxetine (60-100 mg daily) as first-line instead due to no abuse potential 7, 8, 2
Uncontrolled hypertension, symptomatic cardiovascular disease, or active psychosis/mania exists 7, 8
Comorbid tic disorders are severe, though stimulants remain safe and effective in most cases with tics 9, 10
Patient has failed two different stimulant classes (methylphenidate and amphetamine) at adequate doses 10, 4
Common Pitfalls to Avoid
Never prescribe stimulants based on screening scales alone—the absence of an empirically proven symptom threshold means clinical judgment about functional impairment is paramount 1
Do not assume elevated CAARS scores indicate ADHD without ruling out depression, anxiety, or other conditions that can produce similar symptom profiles 4
Avoid treating "subclinical" ADHD symptoms that cause only mild impairment or occur in a single setting, as the risk-benefit ratio does not favor stimulant use 1
Do not rely solely on patient self-report for diagnosis or dose titration—always obtain collateral information from other observers in different settings 1, 3