Attention-deficit hyperactivity disorder monitoring response to therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Template:DE Robert G. Badgett, M.D.[2]


Proposed methods for determining thresholds

Various definitions have been proposed for a response (Reliable Change Index (RCI)) and a remission to treatment.

  • PHQ-9 score of ≤9 combined with improvement of 50% (the original definition)[1]
  • A 30% reduction in a score[2].
  • A 50% reduction in a score[3].
  • Responsiveness statistic of Guyatt is the mean change divided by the square root of 2 x mean square error[4][5]
  • The "response mean (difference of mean scores at 2 assessment points divided by standard deviation of score changes) compute the 95% confidence intervals of the standardized response means"[5][6]
  • One standard error of measurement (SEM) of Wyrich[7][6]
  • Jacobson has suggested[8]:
    • "The level of functioning subsequent to therapy should fall outside the range of the dysfunctional population, where range is denned as extending to two standard deviations beyond (in the direction of functionality) the mean for that population."
    • "The level of functioning subsequent to therapy should fall within the range of the functional or normal population, where range is defined as within two standard deviations of the mean of that population."
    • "The level of functioning subsequent to therapy places that client closer to the mean of the functional population than it does to the mean of the dysfunctional population."[9]

Monitoring response to treatment

Methods of monitoring treatment for ADHD have been reviewed[2].

The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) has higher diagnostic accuracy than the WHO Adult ADHD Self-Report Scale (ASRS)[10].

Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS)

One method is the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS). The WRAADDS has been validated in a clinician administered format[11] and a self-administered format[12]. The self-administered version typically reports about 2 points higher than the clinician adminsitered version. The WRAADDS asks 30 questions in 7 domains, each with Cronbach alpha > 0.7:

  1. Attention Difficulties
  2. Hyperactivity/Restlessness
  3. Temper
  4. Affective Lability
  5. Emotional Over-Reactivity
  6. Disorganization
  7. Impulsivity

Benchmarks for the self-reported version (SR-WRAADDS) are[12]:

  • Subjects without ADHD: 8.5 ± 4.6
  • Subjects with ADHD: 23.4 ± 4.3
    • After treatment, score typically drops by 5 points or effect size (difference / standard deviation) of 0.7

The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) has higher diagnostic accuracy than the WHO Adult ADHD Self-Report Scale (ASRS)[10]. After treatment, score typically drops by 5 points or effect size (difference / standard deviation) of 0.7 "Follow-up scores falling within 1.0 standard deviation of the normal mean". For example, SR-WRAADD of less than 13.1 "30% reduction in symptoms"

ASRS 18-item symptom checklist

The Adult ADHD Self-Report Scale (ASRS) is labeled as the World Health Organization's (WHO) rating scale for adult ADHD. It has 18 items. It also has a 6-item scale for screening. ASRS-v1.1 is available for download at the Attention Deficit Disorder Association at Harvard's[13]

Benchmarks for the ASRS 18-item symptom checklist are 2.0 (SD = 3.2).[14]

  • Thus, response might be defined as a value of 5.2 or 8.4 on the Checklist which are 1 and 2 SDs about the mean of 2.0 for the population without ADHD.
  • "30% reduction in symptoms" score

Conners Abbreviated Symptom Questionnaire (CAARS)

This scale includes the Conners Adult ADHD Rating Scales (CAARS). It has 66 items. CAARS has four subscales[15]:

  • Inattention/memory
  • Hyperactivity
  • Impulsivity
  • Self-concept

The CAARS has been used to measure response to treatment in randomized controlled trials[16].

It is available for download[17].

Affective Lability Scale–Short Form (ALS)

The ALS has 18 items.[18]

Vanderbilt NICHQ

ADHD Rating Scale (for children and adolescents)

For children and adolescents, the ADHD Rating Scale[19] has been used in systematic reviews[20]. In a systematic review, "A clinically meaningful response is generally considered to be improvement of 25% or greater from baseline (a within-group reduction of approximately 10-15 absolute points or a mean difference of approximately 6-7 points between the treatment and placebo groups"[20].

See also


  1. Kroenke K, Spitzer RL, Williams JB (2001). "The PHQ-9: validity of a brief depression severity measure". J Gen Intern Med. 16 (9): 606–13. doi:10.1046/j.1525-1497.2001.016009606.x. PMC 1495268. PMID 11556941.
  2. 2.0 2.1 Ramsay JR (2017). "Assessment and monitoring of treatment response in adult ADHD patients: current perspectives". Neuropsychiatr Dis Treat. 13: 221–232. doi:10.2147/NDT.S104706. PMC 5291336. PMID 28184164.
  3. Gaynes BN, Rush AJ, Trivedi MH, Wisniewski SR, Balasubramani GK, McGrath PJ; et al. (2008). "Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR*D". J Gen Intern Med. 23 (5): 551–60. doi:10.1007/s11606-008-0522-3. PMC 2324144. PMID 18247097.
  4. Guyatt GH, Townsend M, Berman LB, Keller JL (1987). "A comparison of Likert and visual analogue scales for measuring change in function". J Chronic Dis. 40 (12): 1129–33. doi:10.1016/0021-9681(87)90080-4. PMID 3680471.
  5. 5.0 5.1 Wright JG, Young NL (1997). "A comparison of different indices of responsiveness". J Clin Epidemiol. 50 (3): 239–46. doi:10.1016/s0895-4356(96)00373-3. PMID 9120522.
  6. 6.0 6.1 Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K (2004). "Monitoring depression treatment outcomes with the patient health questionnaire-9". Med Care. 42 (12): 1194–201. doi:10.1097/00005650-200412000-00006. PMID 15550799.
  7. Wyrwich KW, Tierney WM, Wolinsky FD (1999). "Further evidence supporting an SEM-based criterion for identifying meaningful intra-individual changes in health-related quality of life". J Clin Epidemiol. 52 (9): 861–73. doi:10.1016/s0895-4356(99)00071-2. PMID 10529027.
  8. Jacobson NS, Truax P (1991). "Clinical significance: a statistical approach to defining meaningful change in psychotherapy research". J Consult Clin Psychol. 59 (1): 12–9. doi:10.1037//0022-006x.59.1.12. PMID 2002127.
  9. McMillan D, Gilbody S, Richards D (2010). "Defining successful treatment outcome in depression using the PHQ-9: a comparison of methods". J Affect Disord. 127 (1–3): 122–9. doi:10.1016/j.jad.2010.04.030. PMID 20569992.
  10. 10.0 10.1 Brevik EJ, Lundervold AJ, Haavik J, Posserud MB (2020). "Validity and accuracy of the Adult Attention-Deficit/Hyperactivity Disorder (ADHD) Self-Report Scale (ASRS) and the Wender Utah Rating Scale (WURS) symptom checklists in discriminating between adults with and without ADHD". Brain Behav. 10 (6): e01605. doi:10.1002/brb3.1605. PMC 7303368 Check |pmc= value (help). PMID 32285644 Check |pmid= value (help).
  11. Marchant BK, Reimherr FW, Robison D, Robison RJ, Wender PH (2013). "Psychometric properties of the Wender-Reimherr Adult Attention Deficit Disorder Scale". Psychol Assess. 25 (3): 942–50. doi:10.1037/a0032797. PMID 23647041.
  12. 12.0 12.1 Marchant BK, Reimherr FW, Wender PH, Gift TE (2015). "Psychometric properties of the Self-Report Wender-Reimherr Adult Attention Deficit Disorder Scale". Ann Clin Psychiatry. 27 (4): 267–77, quiz 278-82. PMID 26554368.
  13. Attention Deficit Disorder Association.
  14. Adler LA, Faraone SV, Sarocco P, Atkins N, Khachatryan A (2019). "Establishing US norms for the Adult ADHD Self-Report Scale (ASRS-v1.1) and characterising symptom burden among adults with self-reported ADHD". Int J Clin Pract. 73 (1): e13260. doi:10.1111/ijcp.13260. PMC 6585602 Check |pmc= value (help). PMID 30239073.
  15. Christiansen H, Hirsch O, Philipsen A, Oades RD, Matthies S, Hebebrand J; et al. (2013). "German validation of the Conners adult ADHD rating scale-self-report: confirmation of factor structure in a large sample of participants with ADHD". J Atten Disord. 17 (8): 690–8. doi:10.1177/1087054711435680. PMID 22441889.
  16. Philipsen A, Jans T, Graf E, Matthies S, Borel P, Colla M; et al. (2015). "Effects of Group Psychotherapy, Individual Counseling, Methylphenidate, and Placebo in the Treatment of Adult Attention-Deficit/Hyperactivity Disorder: A Randomized Clinical Trial". JAMA Psychiatry. 72 (12): 1199–210. doi:10.1001/jamapsychiatry.2015.2146. PMID 26536057.
  17. Australian Council for Educational Research. Available at
  18. Weibel S, Micoulaud-Franchi JA, Brandejsky L, Lopez R, Prada P, Nicastro R; et al. (2019). "Psychometric Properties and Factor Structure of the Short Form of the Affective Lability Scale in Adult Patients With ADHD". J Atten Disord. 23 (10): 1079–1089. doi:10.1177/1087054717690808. PMID 28152669.
  19. DuPaul GJ, Power TJ, Anastopoulos AD, Reid R. ADHD Rating Scale IV (for Children and Adolescents): Checklists, Norms, and Clinical Interpretation. New York, NY: Guilford Press; 1998
  20. 20.0 20.1 Chan E, Fogler JM, Hammerness PG (2016). "Treatment of Attention-Deficit/Hyperactivity Disorder in Adolescents: A Systematic Review". JAMA. 315 (18): 1997–2008. doi:10.1001/jama.2016.5453. PMID 27163988.