What is the proper protocol for utilizing the Conners Self-Assessment Rating Scale (Conners SRS) to screen for Attention Deficit Hyperactivity Disorder (ADHD) in patients?

Utilizing the Conners Self-Assessment Rating Scale for ADHD Screening

The Conners Self-Report should be used only as an initial screening tool, never as the primary method for diagnosing ADHD, because it has unacceptably high false positive rates (78% chance of misidentification at typical prevalence rates) and frequently misidentifies individuals with anxiety or depression as having ADHD. 1, 2

Critical Limitations of the Conners Self-Report

The evidence strongly indicates significant problems with relying on the Conners self-assessment:

• At typical clinical prevalence rates, a positive score on the Conners Adult ADHD Rating Scale (CAARS) has only a 22% chance of accurately identifying true ADHD, with an overall discriminant validity of just 69% 1
• The CAARS demonstrates weak sensitivity, specificity, positive predictive value, and negative predictive value across all subscales, particularly the ADHD Index 2
• Anxiety and depression are the most common conditions causing false positives on the CAARS, meaning patients with these conditions frequently score as having ADHD when they do not 2
• Female patients show particularly poor specificity and positive predictive value compared to males, making the self-report even less reliable in women 2

Proper Protocol for Using Conners Self-Report

Step 1: Initial Screening Only

• Administer the Conners self-report as a preliminary screening tool to identify patients who warrant comprehensive evaluation, but never use the score alone to make or rule out a diagnosis 3, 1
• Recognize that rating scales systematically collect symptom information but do not diagnose ADHD by themselves 3

Step 2: Mandatory Multi-Informant Assessment

If the self-report suggests possible ADHD, you must obtain collateral information:

• Have someone who knows the patient well (parent, spouse, partner) complete the CAARS with the patient in mind to gain insights into how symptoms are perceived by and impact those around them 4
• Gather information from multiple sources across different settings (home, work, social environments) as required by DSM-5 criteria 3
• The multi-informant approach is essential because symptoms must be documented in more than one major setting 3, 5

Step 3: Comprehensive Clinical Evaluation

A positive Conners self-report must trigger a thorough diagnostic evaluation that includes:

• Clinical interview to verify DSM-5 criteria are met: 5+ symptoms of inattention and/or hyperactivity-impulsivity present for at least 6 months, causing impairment in multiple settings 3
• Documentation that symptoms were present before age 12 years, even when retrospective documentation is limited 6
• Systematic screening for conditions that mimic ADHD: anxiety, depression, substance use, sleep disorders, thyroid dysfunction, and other psychiatric conditions that commonly cause false positives 3, 6, 2
• Assessment of functional impairment using validated tools like the Weiss Functional Impairment Rating Scale-Self (WFIRS-S), which measures ADHD-specific impairment in managing home tasks, appointments, and daily responsibilities 4, 7

Step 4: Rule Out Alternative Explanations

Before diagnosing ADHD based on a positive Conners score, you must actively exclude:

• Anxiety disorders and depression (the most common causes of false positives) 2
• Substance use disorders (particularly important in adults) 7, 6
• Trauma-related symptoms that may better explain the presentation 6
• Medical conditions such as thyroid dysfunction, sleep disorders, or medication side effects 7

Common Pitfalls to Avoid

• Never diagnose ADHD based solely on Conners self-report scores, as this leads to misdiagnosis in the majority of cases 1, 2
• Do not skip collateral informant assessment, as self-report alone is insufficient to meet diagnostic criteria requiring impairment in multiple settings 3, 5
• Avoid assigning an ADHD diagnosis when symptoms are better explained by anxiety, depression, or substance use, which are the most common alternative explanations for elevated Conners scores 6, 2
• Do not fail to screen systematically for comorbid conditions, as the majority of individuals with ADHD meet criteria for another mental disorder 6

Investigator-Rated Versions Are More Reliable

When possible, use investigator-rated versions of the Conners scales rather than self-report, as baseline investigator ratings are stronger predictors of treatment outcome and demonstrate better psychometric properties than self-report scores 8