Conners Self-Assessment for Screening Adult ADHD
Role and Limitations
The Conners Adult ADHD Rating Scale (CAARS) should be used only as an initial screening tool, not as the primary method for diagnosing adult ADHD, as it has unacceptably high false positive rates (78% chance of misidentification at typical prevalence rates) and frequently misidentifies individuals with anxiety and depression as having ADHD. 1, 2
Screening Performance
The CAARS demonstrates significant diagnostic limitations in clinical practice:
- Overall discriminant validity is only 69%, with sensitivity of 24-30% and specificity of 97-98% when using conservative cut-offs 1, 3
- At lower prevalence rates typical of clinical settings, a high CAARS score has only a 22% chance of accurately identifying individuals with ADHD 1
- The measure shows particularly poor performance in females, with the lowest internal consistency estimates for DSM Hyperactive/Impulsive Symptoms subscale when completed by women 4
- Anxiety and depression are the most common diagnoses present when false positives occur on the ADHD Index 2
Recommended Assessment Algorithm
The American Academy of Child and Adolescent Psychiatry recommends using the Adult ADHD Self-Report Scale (ASRS-V1.1) Part A as the superior initial screening tool instead of the CAARS, with a positive screen defined as checking "often" or "very often" for 4 or more of the 6 questions 5, 6
If screening is positive, proceed with:
- Comprehensive diagnostic interview using structured tools like the DIVA (Diagnostic Interview for ADHD in adults) to establish childhood onset before age 12 and current functional impairment in at least 2 settings 5, 6
- Collateral information from family members or close contacts using the Conners Adult ADHD Rating Scale-Observer Report (CAARS-O), as adults with ADHD are notoriously poor self-reporters and underestimate symptom severity 5, 6
- Complete psychiatric evaluation to rule out conditions that masquerade as ADHD, including bipolar disorder, depression, personality disorders, anxiety disorders, and substance use disorders 6
Critical Clinical Pitfalls
Do not diagnose ADHD based solely on CAARS scores, as the measure is easily feigned and has poor ability to differentiate ADHD from other psychological complaints 1, 7, 2
- The CAARS can be easily exaggerated or feigned by individuals seeking stimulant medication or accommodations 7, 3
- Neither the CAARS nor its embedded validity indices (CII) adequately detect non-credible adults diagnosed with ADHD 3
- Always obtain collateral information, as self-report alone is insufficient given adults with ADHD underestimate their symptoms and resulting impairments 5, 6
Appropriate Clinical Use
If the CAARS is used, it should serve only as:
- A preliminary screening measure to identify individuals requiring comprehensive diagnostic evaluation 1, 2
- Part of a multi-informant assessment battery that includes the CAARS-Observer Report completed by family members 5
- One component alongside structured diagnostic interviews, collateral history, and assessment of functional impairment using tools like the Weiss Functional Impairment Rating Scale-Self (WFIRS-S) 6
The CAARS should never be the sole or primary basis for making an ADHD diagnosis in adults, given its poor positive predictive value and high rate of misidentification 1, 2