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ADHD Rating Scale-IV: Checklists, Norms, and Clinical Interpretation
- George J. DuPaul, Thomas J. Power, Arthur D. Anastopoulos, and Robert Reid

Chapter 1: Introduction to the ADHD Rating Scales


Attention-Deficit/Hyperactivity Disorder (ADHD) is a diagnostic category used to describe individuals who display developmentally inappropriate levels of inattention, impulsivity, and/or motor activity (American Psychiatric Association, 1994). Approximately 1-5% of school-age children in the United States have ADHD, and these children are at high risk for scholastic underachievement, conduct problems, and problematic social relationships (Barkley, 1998; Hinshaw, 1994). Given the prevalence, chronicity, and myriad difficulties associated with this disorder, it is important for clinicians to use psychometrically sound instruments when evaluating children and adolescents suspected of having ADHD.


Purpose of the Manual

The purpose of this manual is to describe two behavior questionnaires (the ADHD Rating Scale-IV: Home Version and the ADHD Rating Scale-IV: School Version) that are based on the diagnostic criteria for ADHD as described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994). Information is presented about the development and standardization of these scales, collection of normative data, factor structure, psychometric properties (i.e., reliability and validity), as well as the interpretive uses of these scales in clinical and school settings.


Background and Description of the ADHD Rating Scale-IV

Over the past two decades, the diagnostic criteria for ADHD have undergone several changes that have significantly impacted the clinical assessment of this disorder. Consistent with recently espoused theoretical views of this disorder (e.g., Barkley, 1997), factor analyses of teacher ratings of ADHD symptoms according to the criteria of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987) have consistently revealed two separate factors of Inattention and Hyperactivity-Impulsivity (e.g., Bauermeister et al., 1995; DuPaul, 1991). Based, in part, on these findings, DSM-IV provides diagnostic criteria organized into two dimensions of Inattention and Hyperactivity-Impulsivity, each of which consists of nine symptoms.

An evaluation of ADHD typically includes diagnostic interviews with the child and his or her parents and teachers; behavior rating scales completed by parents and teachers, direct observations of school behavior, and clinic-based testing (Barkley, 1998; DuPaul & Stoner, 1994). Although many behavior questionnaires are available for use in such evaluations, very few of the currently available instruments specifically include items directly adapted from the DSM-IV criteria for ADHD. Thus, our purpose in creating the ADHD Rating Scale-IV was to provide clinicians with a method to obtain parent and teacher ratings regarding the frequency of each of the symptoms of ADHD based on DSM-IV criteria.

Eighteen scale items were written to reflect DSM-IV criteria as closely as possible while maintaining brevity. The primary change made to each symptom was to omit the word "often" from the symptomatic description because respondents are asked to indicate the frequency of each symptom on a 4-point Likert scale ("never or rarely," "sometimes," "often," or "very often"). Inattention symptoms comprise the odd-numbered items, and Hyperactive-Impulsive symptoms are represented by the even-numbered items. Alternating symptomatic items in this manner was an attempt to reduce response bias. Parents are asked to make a determination of symptomatic frequency that best describes the child's home behavior over the previous 6 months (in accordance with DSM-IV guidelines), and teachers rate the frequency that best describes the child's school behavior over the previous 6 months or since the beginning of the school year. English and Spanish versions of the ADHD Rating Scale-IV: Home Version are presented in the Appendix, as is the School Version of the ADHD Rating Scale-IV (English only).


Administration and Scoring

Both versions of the ADHD Rating Scale-IV are designed to be completed independently by a child's parent or teacher. The respondent is instructed to provide demographic information (i.e., name of child, age, grade, and name of respondent) and to circle the number for each item that best describes the child's home (or school) behavior over the previous 6 months (or since the beginning of the school year if the teacher has known the child for less than 6 months). If the respondent skips any item, he or she should be asked to provide a rating for this item. If the respondent indicates a lack of opportunity to observe the behavior and skips an item, then this item is not included in the scoring of the scale. If three or more items are omitted, the clinician should use extreme caution in interpreting the scale for screening, diagnostic, or treatment evaluation purposes.

The Home and School Versions of the ADHD Rating Scale-IV both consist of two subscales: Inattention (nine items) and Hyperactivity-Impulsivity (nine items). These subscales are empirically derived (see Chapter 2) and conform to the two symptomatic dimensions described in the DSM-IV. Thus, three scores (Inattention, Hyperactivity-Impulsivity, and Total) are derived from each version. The Inattention subscale raw score is computed by summing the item scores for the odd-numbered items (Items 1, 3, 5, 7, 9, 11, 13, 15, and 17). The Hyperactivity-Impulsivity subscale raw score is computed by summing the item scores for the even-numbered items (Items 2, 4, 6, 8, 10, 12, 14, 16, and 18). The Total Scale raw score is obtained by adding the Inattention and Hyperactivity-Impulsivity subscale raw scores.

Raw scores are converted to percentile scores by using the appropriate scoring profile (presented in the Appendix) based on the child's gender and age. The raw score for a particular gender, age, and scale is circled in the body of the profile. The corresponding percentile score is displayed in the extreme right- and lefthand columns of the profile. Figure 1.1 displays a sample profile for scoring the ADHD Rating Scale-IV: Home Version for a 7-year-old boy. This boy's mother provided ratings resulting in the following raw scores and percentiles: Inattention = 17 (95th percentile), Hyperactivity-Impulsivity = 13 (91st percentile), and Total = 30 (92nd percentile). Note that when a raw score is associated with more than one percentile score (as was the case for this boy's Total score), the clinician should report the lowest of the possible percentile scores.

In Chapter 2, we describe the factor analyses used to derive the subscales of the ADHD Rating Scale-IV. Descriptions of the normative samples, as well as gender, age, and ethnic differences in Scale scores, are given in Chapter 3. The reliability and validity of both versions of the ADHD Rating Scale-IV are detailed in Chapter 4. Chapters 5 and 6 provide clinicians with guidelines for the interpretation and use of the scales for diagnostic and treatment evaluation purposes.line