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Evidence-Based Assessment of Attention Deficit Hyperactivity Disorder in

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 Journal of Clinical Child and Adolescent Psychology Copyright © 2005 by
2005, Vol. 34, No. 3, 449–476 Lawrence Erlbaum Associates, Inc.

Evidence-Based Assessment of Attention Deficit Hyperactivity Disorder

in Children and Adolescents
William E. Pelham, Jr., Gregory A. Fabiano, and Greta M. Massetti
Department of Psychology, State University of New York at Buffalo

This article examines evidence-based assessment practices for attention deficit hyper-
activity disorder (ADHD). The nature, symptoms, associated features, and comorbidity
of ADHD are briefly described, followed by a selective review of the literature on the re-
liability and validity of ADHD assessment methods. It is concluded that symptom rating
scales based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.
[DSM–IV]; American Psychiatric Association, 1994), empirically and rationally de-
rived ADHD rating scales, structured interviews, global impairment measures, and be-
havioral observations are evidence-based ADHD assessment methods. The most effi-
cient assessment method is obtaining information through parent and teacher rating
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scales; both parent and teacher ratings are needed for clinical purposes. Brief,
non-DSM based rating scales are highly correlated with DSM scales but are much more
efficient and just as effective at diagnosing ADHD. No incremental validity or utility is
conferred by structured interviews when parent and teacher ratings are utilized. Obser-
vational procedures are empirically valid but not practical for clinical use. However, in-
dividualized assessments of specific target behaviors approximate observations and
have both validity and treatment utility. Measures of impairment that report functioning
in key domains (peer, family, school) as well as globally have more treatment utility than
nonspecific global measures of impairment. DSM diagnosis per se has not been demon-
strated to have treatment utility, so the diagnostic phase of assessment should be com-
pleted with minimal time and expense so that resources can be focused on other aspects
of assessment, particularly treatment planning. We argue that the main focus of assess-
ment should be on target behavior selection, contextual factors, functional analyses,
treatment planning, and outcome monitoring.

Attention deficit hyperactivity disorder (ADHD) is
one of the most common mental health disorders of
childhood, with prevalence rates ranging from 2% to
9% (American Academy of Child and Adolescent Psy-
chiatry, 1997). By definition, children with ADHD
have deficits compared to other children of the same
age in attending to and completing tasks such as
During the preparation of this article, William E. Pelham, Jr., was
supported by grants from the National Institute of Alcohol Abuse
and Alcoholism (AA11873), the National Institute on Drug Abuse
(DA12414), the National Institute of Mental Health (MH53554,
MH62946, MH065899), the Institute of Education Sciences
(LO3000665A), and the National Institute of Neurological Disor-
ders and Stroke (NS39087). Gregory A. Fabiano was supported by a
National Institutes of Mental Health National Research Service
Award (NRSA 1 F31 MH64243–01A1). Greta M. Massetti was sup-
ported by American Psychological Association/Institute of Educa-
tion Sciences Postdoctoral Education Research Training fellowship
under Department of Education, Institute of Education Sciences
Grant R305U030004.
Requests for reprints should be sent to William E. Pelham, Jr.,
Department of Psychology, State University of New York at Buffalo,
3435 Main Street, 318 Diefendorf Hall, Buffalo, NY 14214. E-mail:
Pelham@buffalo.edu
schoolwork, impulse control, and activity-level modu-
lation. In addition, they have a host of impairments in
multiple domains of functioning, including adult rela-
tionships (e.g., noncompliance with adult requests),
school functioning (e.g., classroom disruption, poor
achievement), and peer and sibling relationships (e.g.,
annoying, intrusive, overbearing, and aggressive be-
haviors). These difficulties continue into adolescence
and adulthood even though core symptoms may im-
prove with age (e.g., Barkley, Fischer, Smallish, &
Fletcher, 2004; Mannuzza & Klein, 1999).
A great deal of research has examined ADHD over
the past three decades, with most of it focused on
psychopathology and treatment (Barkley, in press). Far
less research has been directed toward assessment of
ADHD beyond symptom cut points for a diagnosis.
Few articles have attempted to delineate, for example,
the best ways of combining information across infor-
mants and methods and whether the purpose of assess-
ment influences the answers to questions about best as-
sessment practices.
Our goal is not to exhaustively review the literature
on instruments that have been used to assess children

449
 PELHAM, FABIANO, MASSETTI
with ADHD and their families; such a task would fill a
textbook and would span the range from standardized
tests of intelligence and achievement to measures of
marital functioning in parents. Instead, our focus is on
three fundamental aspects of assessment for ADHD:
(a) the reliability and validity (e.g., concurrent, conver-
gent, discriminant, and incremental) of approaches to
assessing the two requisite features of ADHD—symp-
toms and associated impairment in daily life function-
ing; (b) how different instruments, procedures, and in-
formants are best integrated to produce evidence-based
assessment procedures for clinical practice; and (c)
recommendations for evidence-based procedures with
the best treatment utility and cost effectiveness.
BACKGROUND
Purposes of Assessment
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The evidence base for assessment may vary as a
function of the purpose of assessment (Mash & Huns-
ley, 2005)—diagnosis, prognosis, treatment planning,
or evaluation of outcome (Mash & Terdal, 1997).
These purposes may vary depending on the setting in
which assessment occurs. In research settings—for ex-
ample, epidemiological or clinical studies— diagnos-
tic assessments based on the Diagnostic and Statistical
Manual of Mental Disorders (4th ed. [DSM–IV];
American Psychiatric Association, 1994) are con-
ducted to determine whether a child’s behavior devi-
ates from normative child behavior sufficiently to meet
criteria for a diagnosis. The goal is to maximize diag-
nostic homogeneity and thus etiological and prognos-
tic homogeneity (though it is not clear that the former
assures the latter). If the study has a longitudinal com-
ponent, prognosis is also a purpose of the diagnosis. In
basic research studies, assessment typically ends with
the diagnosis.
In clinical settings, diagnosis is also a purpose of as-
sessment, although its main use is typically administra-
tive (e.g., eligibility for services, reimbursement). The
underlying, fundamental reason for clinical assess-
ment goes well beyond diagnosis—to determine the
need for treatment, conceptualize the case, specify
treatment goals, develop treatment targets, and monitor
progress and outcome.
Consider, for example, the primary care setting,
where the majority of children with ADHD will receive
initial evaluations (Hoagwood, Kelleher, Feil, &
Comer, 2000). Recognizing the importance of accu-
rately assessing and treating ADHD, the American
Academy of Pediatrics (AAP; 2000, 2001) developed
practice guidelines for the diagnosis, evaluation, and
treatment of ADHD. The diagnostic guidelines state
that primary care physicians should (a) screen for
ADHD when core symptoms are present, (b) employ
DSM–IV criteria, (c) gather information about DSM–IV
450
symptoms directly from parents and teachers, (d) assess
for functioning and coexisting conditions, and (e) not
use diagnostic tests other than DSM– IV-based rating
scales. The AAP (2001) treatment guidelines expand
greatly on assessment, using the term target outcomes
rather than symptoms to ensure that practitioners would
broadly conceptualize the targets of treatment for
ADHD. Clinicians are told to work with parents and
schools to target domains for intervention and to mea-
sure resulting target outcomes over time to evaluate the
effectiveness of treatment. Thus, the purpose of assess-
ment in the AAP guidelines is relatively narrowly de-
fined when the goal is diagnosis but more broadly con-
ceptualized when treatment is the focus.
As in primary care, the main initial purpose of as-
sessment in mental health and educational settings is to
provide a diagnosis. After diagnosis, the main ques-
tions left to address involve treatment—whether the
child is sufficiently impaired to need medication (pri-
mary care question), therapy (mental health), or special
services (education) and then to evaluate treatment
outcomes. Thus, all purposes of assessment after diag-
nosis in clinical settings involve planning for or moni-
toring treatment, and assessment for ADHD must be
designed to easily incorporate these functions.
There are two classes of logical targets for interven-
tion in ADHD: the DSM–IV symptoms, and the various
impairments in daily life functioning and deficient
adaptive skills for which children are referred. These
domains are not mutually exclusive, but neither do they
overlap completely. Target behaviors could include (a)
attention, impulsivity, and hyperactivity; (b) peer rela-
tionship difficulties, academic achievement, and dys-
functional parenting skills; or both. We take the position
that symptoms of ADHD are not socially valid targets
for intervention and that beyond their use to make
DSM–IV diagnoses, there is little reason to focus on
them in a comprehensive, cost-effective approach to as-
sessment. We argue instead that the common domains of
impaired functioning discussed in this article are the
reasons that children with ADHD are referred, the medi-
ators of their long-term outcomes, and the most appro-
priate targets for initial assessment, intervention, and
monitoring. Thus the main focus of assessment in
ADHD should be impairment and adaptive skills. Fur-
ther, beyond identification of target outcomes in these
domains, assessment should focus on functional behav-
ioral assessments (FBA) of these target domains with
the goals of treatment planning and monitoring (Gres-
ham, Watson, & Skinner, 2001). As we discuss here, the
literature on assessment of ADHD has focused almost
exclusively (but not entirely) on measuring the core
symptoms of ADHD to yield DSM–IV diagnoses. There
is thus a disconnection between the activities and tools
with which clinicians should be familiar and the activi-
ties and tools they typically use to assess ADHD. We
discuss this in more depth later.
 ADHD ASSESSMENT

Nature of ADHD from existing empirically developed rating scales (e.g.,

Conners, 1969; Quay & Peterson, 1983). Some of the
For the past 40 years, it has been widely accepted
symptoms (e.g., often loses things necessary for tasks
that the core symptoms of ADHD are inattention,
or activities) resulted directly from empirical work
impulsivity, and hyperactivity. As the DSM has gone
(Atkins, Pelham, & Licht, 1985). Others (e.g., is often
through three editions and as theories of ADHD have
easily distracted by extraneous stimuli) have persisted
been modified, which symptoms have been considered
because they are especially salient as reported by par-
preeminent and how they should best be combined to
ents and teachers (e.g., Milich, Widiger, & Landau,
yield an ADHD diagnosis or diagnostic subtype have
1987) despite fairly consistent failure in controlled
changed. Early theorists focused mostly (though not
studies to find supportive evidence (Huang-Pollock &
exclusively) on inattention, whereas more recently im-
Nigg, 2003). Other symptoms (e.g., often engages in
pulsivity and disinhibition has been considered the
physically dangerous activities without considering
core cognitive deficit (Barkley, 1997). The precise na-
the possible consequences; often acts without think-
ture of the attentional and impulse control deficits has
ing) have been dropped from the DSM list despite evi-
been widely studied and debated (Douglas, 1999;
dence that they are among the most discriminating
Huang-Pollock & Nigg, 2003; Sergeant, Oosterlaan, &
items or have high face validity (Frick et al., 1994; Pel-
Van Der Meere, 1999). Most recently, the constructs of
ham, Gnagy, Greenslade, & Milich, 1992). The fact
executive dysfunction and frontal lobe functioning
that impulsivity items are embedded within—and ar-
have played prominent roles in discussions of the core
guably diluted by—twice the number of hyperactivity
cognitive deficit in ADHD (Barkley, in press). Re-
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items may contribute to counterintuitive findings re-

search has been extended to the use of functional MRI
and molecular genetics to examine biological differ-
ences between ADHD and comparison children (e.g.,
Castellanos et al., 2003; Castellanos & Swanson,
2002), though reliable markers of ADHD are yet to be
demonstrated.
Our lack of understanding of the biological or cog-
nitive basis of ADHD may well be one reason that tests
and procedures that tap those domains are not currently
useful in diagnosis or assessment (AAP, 2000; Barkley,
in press; Epstein et al., 2003; Matier-Sharma, Perachio,
Newcorn, Sharma, & Halperin, 1995; Rapport, Chung,
Shore, Denney, & Isaacs, 2000). Because the definition
of ADHD is currently a behavioral one based on the in-
dividual’s functioning in daily life (APA, 1994), as-
sessment procedures must focus on the observable be-
havior as reported by adults or otherwise measured in
natural (home and classroom) and laboratory (clinic,
analogue classroom) settings.
DSM–IV Symptoms of ADHD
Despite the shifts in emphasis and the debate about
the fundamental cognitive deficit, the core characteris-
tics of ADHD have remained consistent for three de-
cades. Thus, the current DSM–IV definition lists nine
behavioral descriptors of inattention and nine descrip-
tors of impulsivity/hyperactivity (APA, 1994). A diag-
nosis is given if (a) six symptoms from either or both
lists is met (inattentive type, hyperactive–impulsive
type, or combined type), (b) the symptoms are mal-
adaptive and inconsistent with developmental level, (c)
symptoms began before the age of 7 years, and (d)
symptoms have associated clinically significant im-
pairment in two or more settings.
Most of the current symptoms listed in DSM–IV
came from the two previous editions and before that
garding the relative weight of inattention versus im-
pulsivity in predicting outcomes among ADHD sam-
ples (e.g., Molina & Pelham, 2003). Indeed, subsets of
items from the DSM–IV, including those that are word-
ed slightly differently and appear on empirically de-
rived scales, appear to be just as reliable, valid, and dis-
criminating as the entire DSM–IV symptom list (see
following discussion). To the extent that almost all of
the work on assessing ADHD has had as its goal as-
sessing the DSM–IV symptoms, the literature is by def-
inition limited by the nature and grouping of those
items.
As the symptom criteria have changed in sub-
sequent editions of the DSMs, so too has subtyping
of ADHD. The fact that the symptoms were listed in
three (Diagnostic and Statistical Manual of Mental
Disorders, 3rd ed.; American Psychiatric Association,
1980), one (Diagnostic and Statistical Manual of Men-
tal Disorders, 3rd ed., rev.; American Psychiatric As-
sociation, 1987), and two (DSM–IV) clusters reflected
changing thinking among researchers based mainly on
factor analytic studies (e.g., Lahey et al., 1988).
Children diagnosed with the DSM–IV hyperactive–im-
pulsive subtype are relatively rare and consist of pre-
dominantly young (e.g., kindergarten-age) children
(Lahey et al., 1994) who will become diagnosed as
combined type when they reach the age in school
where sustained attention to task is required (Lahey,
Pelham, Loney, Lee, & Willcutt, in press). The inatten-
tive subtype has been shown to be distinct from the
combined type not only by definition—not having a
sufficient number of hyperactive–impulsive symptoms
—but also by virtue of differential associated features
including severity, impairment, familial history, and
outcomes (Milich, Balentine, & Lynam, 2001). How-
ever, with respect to assessment, the same procedures
need to be employed for assessing subtypes of ADHD,

451
 PELHAM, FABIANO, MASSETTI
because the subtypes have a common set of symptoms
that result in similar functional impairments (Pelham,
2001).
Impairment in ADHD
Although both are required, researchers, clinicians,
and school personnel often emphasize the importance
of obtaining an accurate assessment of DSM–IV symp-
toms with relatively less emphasis on the assessment of
impairment. This may be misplaced for some of the
purposes of assessment. For example, DSM–IV symp-
toms of ADHD do not predict long-term outcome (e.g.,
Mannuzza & Klein, 1999) and are not the basis of re-
ferrals for treatment (Angold, Costello, Farmer, Burns,
& Erkanli, 1999). In contrast, three areas of psychoso-
cial impairment common in ADHD children—diffi-
culties in family functioning, peer relationships, and
academic functioning—are predictive of negative long-
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term outcome, are typically the basis of referral, and
arguably are the target behaviors that must be modified
to improve both current and long-term functioning
(e.g., Angold et al., 1999; Chamberlain & Patterson,
1995; Huesmann, Eron, Lefkowitz, & Walder, 1984;
Jimerson, Egeland, Sroufe, & Carlson, 2000). We dis-
cuss each of these three domains in the following.
Children with ADHD live in families with a host of
problems that both impact and are impacted by the
child. Relative to comparison groups, parents of chil-
dren with ADHD report more frequent and severe
interparental discord and child-rearing disagreements,
more negative parenting practices, greater parenting
stress and caregiver strain, and more psychopathology
themselves (Johnston & Mash, 2001). These factors
both contribute to and are exacerbated by the child’s
ADHD (e.g., Lang, Pelham, Atkeson, & Murphy,
1999; Pelham et al., 1998) and highlight the impor-
tance of assessing the familial context of children with
ADHD, including the nature of parenting skills, which
both predict and mediate long-term outcomes and are
thus key targets for intervention.
The source of most complaints about ADHD is the
classroom teacher. Indeed, studies of children with
ADHD in classroom settings have routinely docu-
mented that they are more off-task, complete less as-
signed work with less accuracy, are more disruptive
and break more classroom rules, and are less likely to
comply with adults compared to other children (e.g.,
Atkins et al., 1985). These behaviors contribute to
lower levels of academic achievement and higher rates
of disciplinary referrals, retention, and later dropout
(e.g., DuPaul & Stoner, 2003). Comprehensive assess-
ment of ADHD must therefore include evaluation of
classroom behavior and academic functioning.
It has long been known that most children with
ADHD have severe difficulties interacting with other
children (Milich & Landau, 1982; Nangle & Erdley,
452
2001). They are bossy, intrusive, immature, boisterous,
boastful, less aware of social cues, and aggressive—
both physically and verbally—relative to other chil-
dren. Numerous studies have documented these dif-
ficulties in multiple settings (Cunningham & Siegel
1987; Hinshaw & Melnick, 1995). Peer nomination
procedures reveal that children with ADHD or high
levels of ADHD behaviors are dramatically more dis-
liked and less well liked than comparison children
(Pelham & Bender, 1982). Although not all children
with ADHD have problems with peers, disturbances in
peer relationships are among the best predictors and
mediators of a variety of adverse adult outcomes (Coie
& Dodge, 1998; Huesmann et al., 1984) and are a key
focus of assessment in ADHD.
There are many well-validated, standardized instru-
ments used to assess functioning in the domains of
family relationships, peer relationships, and school
functioning. These include parent, teacher, and peer re-
ports and direct assessments of IQ and academic
achievement. In contrast, the child’s general lack of in-
sight into problem areas and concomitant overestima-
tion of abilities and skills in specific functional do-
mains (e.g., academic and social performance; Hoza,
Pelham, Dobbs, Owens, & Pillow, 2002), along with
the low reliability of child report (e.g., Shaffer, Fisher,
Lucas, Dulcan, & Schwab-Stone, 2000), underscore
the lack of support for child report in clinical assess-
ments for ADHD (Hart, Lahey, Loeber, & Hanson,
1994; Loeber, Green, & Lahey, 1990). Because of
these factors, child report is not a valid method of ob-
taining an ADHD diagnosis or planning for treatment.
Comorbidity
Epidemiological surveys (e.g., August, Realmuto,
MacDonald, Nugent, & Crosby, 1996; Pelham, Evans,
Gnagy, & Greenslade, 1992) and clinical studies (e.g.,
MTA Cooperative Group, 1999a, 1999b) evidence
high concentrations of comorbid DSM disorders in
samples of children with ADHD. The highest comor-
bidity is between ADHD and disorders related to ag-
gression (i.e., children with oppositional defiant disor-
der and conduct disorder; Lahey, Miller, Gordon, &
Riley, 1999) and learning problems, with much lower
rates of comorbid internalizing problems (MTA Coop-
erative Group, 1999a).
The procedures for making DSM–IV diagnoses of
comorbidities are similar to the procedures for ADHD
with a few exceptions (see other articles in this special
section), and we do not discuss them here. However, a
critical question in the assessment of comorbid disor-
ders is identical to assessments for ADHD—should a
DSM–IV diagnosis be the main focus? Though many
children with ADHD meet criteria for comorbid diag-
noses, the diagnosis is of little use beyond studies of
epidemiology. This is because comorbid diagnoses per
 ADHD ASSESSMENT
se typically have small to no effect on treatment out-
come or approach (e.g., Kolko, Bukstein, & Barron,
1999; MTA Cooperative Group, 1999b). The nature of
the associated impairment—that is, what behaviors
will be targeted in treatment—is of much greater value
for clinicians (Pelham & Fabiano, 2001). For example,
it is widely thought that a comorbid diagnosis of con-
duct disorder confers increased risk for antisocial out-
comes among children. However, the bulk of the extant
longitudinal literature actually employs parent, teach-
er, and peer ratings of aggressive and disruptive behav-
ior and peer nominations of disliking and rejection—
that is, measures of impairment—not DSM–IV conduct
disorder diagnoses (Coie & Dodge, 1998).
The most parsimonious approach to diagnosing
comorbidities is arguably to rely on rating scales that
have broad coverage of symptoms rather than employ-
ing a full diagnostic structured interview, which would
be costly and time intensive. In keeping with the theme
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of our approach, the assessment of comorbidity is inte-
grated into the broader assessment goals of using an
FBA to operationalize the presenting problems and
gathering information on setting events and anteced-
ents, as well as environmental contingencies that may
precipitate, maintain, or exacerbate the behavior.
These targeted behaviors are then tracked along with
outcomes associated with ADHD to determine
whether meaningful change has been obtained.
Review of the Evidence for ADHD
Assessment Methods
In the following we discuss each of the major tech-
niques involved in assessment and the evidence for the
respective techniques. As recommended in most guide-
lines for diagnosis and assessment (e.g., American
Academy of Child and Adolescent Psychiatry, 1997;
AAP, 2001), we focus on gathering information from
adults in the child’s life via ratings and interviews and
from observational data in the natural setting, and we
deal with both symptoms of ADHD and ADHD-re-
lated impairments.
Numerous, comprehensive reviews are available on
assessment strategies for ADHD (e.g., Anastopoulos &
Shelton, 2001; Barkley, in press; Collett, Ohan, &
Meyers, 2003; Hinshaw & Nigg, 1999), and there are a
number of well-developed, commercially available rat-
ing scales for assessing ADHD and related impairment,
both narrow and broadband. Our purpose in this section
is to selectively review the literature and determine the
evidence-base for some of the more common assess-
ment instruments utilized for children with ADHD in re-
search and clinical practice. This review is therefore not
exhaustive and is limited by the measures chosen for in-
clusion. At the same time, most instruments within a
method of assessment (e.g., rating scales) have similar
levels of evidence and psychometrics, so some degree of
generalization to instruments not reviewed would be ap-
propriate. In some cases, the method of assessment is
generic (e.g., individualized daily target behavior fre-
quencies), and we have selected studies of which we are
aware that presumably accurately reflect a much larger
universe of use in practice.
Table 1 displays information on the reliability and
validity of common ADHD assessment measures.
When available, we present information on internal
consistency (i.e., the relation among the individual
items on the scale), test–retest reliability (i.e., temporal
stability), and interrater reliability (the relation among
independent raters’ scores). The second section of the
table displays validity information for each measure.
When available, we present information on concurrent
validity (i.e., the relation between the measure and
similar measures), predictive validity (i.e., the ability
of the measure to accurately discriminate between
groups), and convergent and discriminant validity (i.e.,
the relation of the measure to others, correlating with
measures purported to assess the same construct and
not correlating with measures purported to assess a dif-
ferent construct; Campbell & Fiske, 1959). We also
note whether the measure is sensitive to behavioral and
pharmacological treatment effects.
ADHD Symptom Rating Scales
Rating scales of ADHD-like behavior have been
used since the late 1960s to describe and diagnose par-
ticipants in research studies and to measure treatment
outcomes (e.g., Conners, 1969; Goyette, Conners, &
Ulrich, 1978; Quay & Peterson, 1983). The first DSM–
IV symptom based rating scale of ADHD, the Swanson
and Pelham Rating Scale (Atkins et al., 1985), was
constructed because no parent or teacher rating scale of
the Diagnostic and Statistical Manual of Mental Dis-
orders (3rd ed.) attention deficit disorder symptoms
existed. Swanson and Pelham wanted to make a diag-
nosis using the new attention deficit disorder category
to enroll individuals in a study, so they listed the Diag-
nostic and Statistical Manual of Mental Disorders (3rd
ed.) symptoms of attention deficit disorder using the
response format of the widely used Conners Rating
Scales. Since then, many rating scales have been devel-
oped based on the Swanson, Nolan, and Pelham Rating
Scale.
There are few differences among these scales be-
yond the range of items assessed. For example, the Dis-
ruptive Behavior Disorders rating scale (Pelham et al.,
1992) includes Diagnostic and Statistical Manual of
Mental Disorders (3rd ed., rev.) and DSM–IV ADHD
symptoms, making it useful in research settings where
comparisons to studies that used prior DSM algorithms
are desired. It also includes the DSM–IV symptoms of
oppositional defiant disorder and conduct disorder.
453
 454

Table 1. Summary of Reliability and Validity Information for Rating Scales of ADHD Symptoms, Broadband Behavior Rating Scale Subscales, Structured and Semistructured Interviews, and
Ratings of Psychosocial Impairment
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Reliability Validity

Sensitive Measure
Type of Internal Convergent of Treatment
Measurea Type of Rating Scale Consistency Test–Retest Interrater Concurrent Predictive and Discriminant Outcome

DSM–IV Swanson, Nolan, & Pelham
ADHD rating scale (SNAP; Atkins
rating scale et al., 1985; Atkins et al.,
1988; Gaub & Carlson,
1997; MTA Cooperative
Group, 1999a; Pelham &
Bender, 1982)
Disruptive Behavior
Disorders rating scale
(DBD; Massetti et al.,
2003; Pelham Gnagy, et
al., 1992, Pelham, Evans,
et al., 1992; Pelham &
Hoza, 1996)
ADHD rating scale (DuPaul,
1991; DuPaul,
Anastopoulos, et al., 1998;
DuPaul et al., 1997;
DuPaul, Power, et al.,
1998; Gomez et al., 1999;
Power et al., 1998)
Vanderbilt rating scale
(Wolraich et al., 1998;
Wolraich et al., 2003)
Not reported r = .77 to .80 (T) Not reported r (SNAP Impulsivity Different subtypes of Convergent: r = .23 to .35 for Sensitive to
score, SNAP Peer ADHD exhibit measures of academics; r = behavioral and
interaction items) differential patterns of .31 to .37 for observations pharmacological
= .73 impairment relative to of verbal intrusion. treatment effects
a control group Discriminant: Academic in multiple
measures and group play studies
observational measure
discriminated between
teacher ratings of H-I/I and
peer relationships
α = .91 to .96 r = .49 to .61 (P, r = .14 to .26 (P, r (P DBD rating Not reported Not reported Sensitive to
(T) α = .82 before T) scale, DISC) = .38 behavioral and
to .85 (P) treatment/after to .62 pharmacological
treatment) treatment effects
in multiple
studies
α = .88 to .95 r = .55 to .90 (T); r = .40 to .59 (P, r (ADHD rating Statistically significant Some evidence for Not established
(T) α = .86 r = .70 to .86 T) scale, T Conners) differences in mean discriminant validity of H/I (though items are
to .92 (P) (P) = .80 to .88 (T). r scores between and I scales. Moderate identical to other
(ADHD rating ADHD and control correlations with symptom rating
scale, Abbrev groups (P, T); observations of on-task scales used to
Conners T scale) = Effective in predicting behavior. For I factor, measure
.77 to .90. r ADHD subgroup and moderate correlations with treatment effects)
(ADHD rating ADHD versus control academic productivity (P, T)
scale, P Conners) group membership.
= .68 to .84 (P)
α = .90 to .94 Not reported r = .32 (P, r (P Vanderbilt rating Not reported r (T rating I, measures of Not established
(T). α = Identified child scale, C–DISC) = impairment) = .50 to .66. r (though items are
.94 to .95 with ADHD; T, .79 (T rating H/I, measures of very similar to
(P). Identified child impairment) = .23 to .63. other symptom
with ADHD). T rating scale H-I/IA rating scales used
correlated with learning to measure
problem status to a much treatment effects)
lesser extent.
 ADHD Symptom α = .87 to .92 r > .65 (P). r = . r = .23 to .51 (P, r ADHD diagnoses, When P and T ratings Convergent/discriminant Not established
Checklist–4 (Gadow & (P). α = .75 to .85 (T) T). r = .50 to Attention are combined, validity with CBCL (though items are
Nolan, 2002; Gadow & .94 to .95 .54 (T, teacher problems(ADHD Sensitivity = .91 attention problems and identical to other
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Sprafkin, 1997; Gadow et (T). aide). Symptom delinquency factors. symptom rating
al., 2001; Mattison et al., Checklist 4, TRF) scales used to
2003; Sprafkin et al., 2001; = .35 to .78. measure
Sprafkin et al., 2002) treatment effects)
Broad band CBCL/TRF (Achenbach, α (CBCL) = r (CBCL) = .90 r (CBCL) = .93 to r (CBCL attention CBCL, TRF competency Multitrait method matrix in Sensitive to
rating 1991; Achenbach & .84. α (1-week), .71 to .96 (interviewer), problem scale, scales lower and CBCL/TRF manuals behavioral
scales Edelbrock, 1981; (TRF) = .77 (1-year), .75 .79 (interparent). Conners) = .59. r problem scales higher illustrating convergent treatment effects
Achenbach & Rescorla, .94. (2-year). r r = .61 (CBCL, Behavior in clinically referred validity of the scale. in multiple
2001; Anastopolous et al., (TRF) = .96 (interteacher), problem checklist) youth versus studies
1993; Barkley et al., 2000; (15-day), ,77 .62 (teacher- = .66 to .77. r nonreferred youth.
Ostrander et al., 1998) (2-month), .73 aide). (TRF, Conners) =
(4-month). .80.
Child Attention Problems Split-half r = Test–retest r = .96 r (interteacher) = r (other ADHD Discriminated between Not reported Sensitive to
(Barkley, 1990; Barkley et .84 (2 weeks), .76 .77 symptom rating children referred for pharmacological
al., 1990; Power, Andrews, (2 months), .70 scales) >>.90 services and those not treatment effects
et al., 1998) (4 months) referred; Discriminated
between children with
H/I and those without
The Behavior Assessment Attention Attention problem r (teacher 1, BASC scales Groups of children with Not reported Not established
System for Children problem Composite r = teacher 2) = .63 correlate highly preexisting diagnoses
(BASC; Ostrander et al., Composite .83 to .92 (T), to .69; with exhibit distinct BASC
1998; Reynolds & α = .85 to .78 to .92 (P) r(mother, corresponding profiles; differentiates
Kamphaus, 2002) .87 (T), .76 father) = .56 to CBCL/TRF scales between attention
to .81 (P) .73 and the Conners problems and
Rating scale. hyperactivity–
impulsivity.
Conners Parent and Teacher α = .73 to .95 r = .47 to .87 (T). r (Mother, Father) r (CBCL attention Overall correct Convergent and discriminant Sensitive to
rating scales (I and HI (T). α = r = .71 to .78 = .55. r (Parent, problem scale, classification rate = validity supported by behavioral and
subtests; Achenbach, 1991; .75 to .94 (P). Teacher) = .49. Conners) = .59. R 93.4% (P) and 84.7% multitrait, multimethod pharmacological
Conners et al., 1998a, (P) (CBCL, Behavior (T). matrix treatment effects
1998b, Goyette, et al., problem checklist) in multiple
1978; Roberts et al., 1981) = .66 to .77. r studies
(TRF, Conners) =
.80.
IOWA Conners Rating scale α (T I/O) = r (T I/O) = .89. r r (teacher, Not reported Differentially identifies Academic variables, peer Sensitive to
(Atkins et al., 1989; Kolko .80 to .89. (T I/O, 2-year) teacher) = .35 children with relationship variables, neat behavioral and
et al., 1999; Loney & α (T O/D) = .42. r(T O/D) to .49 hyperactive behavior desktop, and behavioral pharmacological
Milich, 1982; Milich et al., = .85 to = .86 versus aggressive observations of disruptive treatment effects
1982; Pelham et al., 1989; .92. r (I/O, behavior. behavior differentiate I/O in multiple
Pelham et al., 1993) O/D) = .60 Discriminated ADHD from O/D factor. studies
to .63 children from
controls.
455

(continued)
 456
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Table 1. (Continued)
Reliability Validity

Sensitive Measure
Type of Internal Convergent of Treatment
Measurea Type of Rating Scale Consistency Test–Retest Interrater Concurrent Predictive and Discriminant Outcome

Structured Diagnostic Interview for r > .90, κ = κ = .78 to . 86 for κ = –.01 to .34 Not reported Good concordance, Not reported Not established
Interviews Children and .60, ICC = parents, .24 to (parent vs. specificity, and
Adolescents–Revised .75 .43 for self-report); .71 sensitivity of
(DICA–R; August, self-reports (lay vs. assessment and
Braswell, & Thuras, 1998; psychiatrist diagnosis reported
Boyle et al., 1993; Reich, reports)
2000; Reich, Shayka, &
Taibleson, 1991)
Diagnostic Interview κ = .60 (P), 79 (P), .42 (Y), .70 (P), .10 (Y), 72(P), .27(Y), Exhibited excellent Classifications using DISC at Sensitive to
Schedule for Children .10(Y), .62 (P+Y) .48 (P+Y) for .70(P+Y) (r with ability to discriminate higher risk for indexes of behavioral and
Version IV (DISC–IV; .48(P+Y); symptom clinician scores); probands relative to impairment (i.e., school pharmacological
Jensen et al., 1996; ICC = counts; .65 (P), however, only the CBCL dysfunction, family treatment effects
Lewczyk et al., 2003; MTA .84(P), .19 (Y), .56 minor diagnostic distress) for parent but not
Cooperative Group, 1999a; .65(Y), (P+Y) for agreement with child reports
Shaffer et al., 2000) .79(P+Y); criteria + clinician ratings
κ = .22 impairment
Semistructured Kiddie Schedule for Not reported Not reported for κ = .56 Demonstrated Discriminated between Not reported Not established
interviews Affective Disorders and for ADHD; ADHD excellent children with ADHD
Schizophrenia (K–SADS; moderate convergence with and children with
Biederman et al., 1993; to strong CBCL Attention bipolar disorder
Orvaschel, 1985; Tillman for Problems scale
et al., 2003) affective
and
conduct
disorders
Child and Adolescent Not reported Not reported for Concordance with Significant relations Not reported CAPA interviews reflect Not established
Psychiatric Assessment for ADHD ADHD interviewer with CBCL and clinical and research
(CAPA; Angold & ratings of TRF scores experience and prevalence
Costello, 2000) inattention and data, comorbidity patterns;
H/I children diagnosed using
CAPA are at increased risk
for impaired functioning
 Impairment Columbia Impairment Rating r = .82 to .89 r = .89 (P); r = .63 Not reported r (P CIR, P CGAS) = Mean scores higher in Correlations with other Not established
rating scale (CIR; Bird et al., (P); r = .70 (Child) .35 to .73. r (Child clinical participants measures of psychological
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scales 1993; Bird et al., 1996) to .78 CIR, Child compared to dysfunction = .32 to .71
(Child). CGAS) = .48 to community (P), .08 to .41 (Child).
.50. respondents
Children’s Global Not reported r = .74 to .84 (Cl) r = .69 to .87 (Cl) r (CGAS, GAF) = Scores associated with Not reported Not established
Assessment of Functioning .87 to .92; r service use and need,
(CGAS; Bird et al., 1987; (CGAS, severity and behavior problem
Bird et al., 1990; Shaffer, scale) = .80 to .90; ratings. Significant
et al., 1983) r (CGAS, P mean score difference
Abbreviated between clinical cases
Conners) = .25; r and controls and
(CGAS, CBCL) = accurate classification
.40 to .65 rates.
Impairment Rating Scale Not reported r (1-year) = .40 to r (P,T) = .33 to .83 r (IRS, P CGAS) = Positive predictive power Evidence for convergent Sensitive to
(IRS; Evans et al., under .67 (T). r (1- ..62 to .77 (T). r = .85 to .92 (T). validity, the IRS correlated behavioral and
review; Fabiano et al., year) = .54 to (IRS, Interviewer Negative predictive moderately with behavioral pharmacological
under review; Pelham & .76 (P). T r = CGAS) = .55 to power = .82 to .91 (T). observations and frequency treatment effects
Hoza, 1996) .64 to .89 (6- .73 (P). Postive predictive counts of behavior.
month); .57 to power = .91 to .97 (P).
.84 (4-month); Negative predictive
.66 to .98 (2- power = .80 to 1.00
month). P r = (P); Predicts use of
.60 to .89 (6- mental health or
month); .76 to school services
.91 (4-month);
.82 to .95 (2-
month).
Vanderbilt Rating Not reported Not reported r (Classroom Not reported Not reported r (Classroom Behavior Not established
Scale–Teacher Version Behavior Performance, ADHD
(Wolraich et al., 1998) Performance) = symptoms) = .53 to .66; r
.94; r (Academic Performance,
(Academic ADHD symptoms) = .23 to
Performance) = .50
.95
Child and Adolescent r = .73 to .78 Not reported r (Total) = .92 to Not reported Higher impairment Higher impairment associated Sensitive to
Functional Assessment .96 ratings associated with with behavioral indices of behavioral
Scale (CAFAS; Hodges et more “severe” impairment (i.e., poor treatment effects
al., 1999; Hodges & Wong, disorders. grades and school
1996) attendance, contact with
the law).

(continued)
457
 458

Table 1. (Continued)
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Reliability Validity

Sensitive Measure
Type of Internal Convergent of Treatment
Measurea Type of Rating Scale Consistency Test–Retest Interrater Concurrent Predictive and Discriminant Outcome

Observations Classroom Observations of Not reported Not reported Phi coefficient = Not reported Discriminant function Convergent or discriminant Sensitive to
Conduct and Attention .52 to .95 (all reliably identified validity with teacher behavioral and
Deficit Disorders but one > 60). κ children with ADHD ratings of inattention and pharmacological
(COCADD; Atkins et al., (classroom) = and those without. aggression treatment effects
1985; Atkins et al., 1988; .67 to 1.00. κ in multiple
Atkins et al., 1989) (playground) = studies
.79 to 1.00. κ
(Desk
observations) =
.60 to .79
Classroom behavior code Not reported As expected, Mean Phi Not reported Accurately discriminated Not reported Sensitive to
(Abikoff et al., 1977, 1980; ADHD group coefficient for between hyperactive behavioral and
Klein & Abikoff, 1997; had greater interobserver and comparison pharmacological
MTA Cooperative Group, variability agreement = .76 children and code treatment effects
1999a) across to .82 accurately classifies in multiple
categories over children in groups studies
successive (80% correctly
observations. classified)
Response Class Matrix Not reported Not reported Interobserver Not reported Observation code Not reported Sensitive to
(Barkley & Cunningham, agreement = .76 differentiated between pharmacological
1979; Cunningham & to .97 children with ADHD treatment effects
Barkley, 1979; and those without. in multiple
Cunningham & Siegel, studies
1987; Mash & Johnston,
1982; Mash, Terdal, &
Anderson, 1973)
Playroom Observations Not reported r (Free play, Interobserver Not reported Not reported Observations of behaviors in Not established
(Milich et al., 1982, 1986) 2-year) = .08 to agreement = .87 both settings uniquely
.53. r to .95 accounted for variance on
(Restricted the Conners Hyperactivity
academic, factor; Observations
2-year) = –.09 differentiated between
to .57. Hyperactivity and
Aggression factors
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Barkley (Barkley, 1990; Not reported Not reported Interobserver Not reported Not reported r = .25 to .30 for parent Sensitive to
Barkley et al., 2000; agreement = .77 ADHD ratings and behavioral
DuPaul, 1991) to .85 observations of on-task treatment effects
class behavior; r = .46 to
.57 for teacher ADHD
ratings and observations of
on-task class behavior
STP point system (Chronis et Not reported r (Placebo Interobserver r (STP point system, Discriminates between Not reported Sensitive to
al., 2004; Pelham et al., condition, Low agreement = .66 Observational ADHD and behavioral and
1993; Pelham, Greiner, & MPH to .98; κ measure) = .43 to comparison children pharmacological
Gnagy, 1998; Pelham & condition) = (following 1.00; M = .72. treatment effects
Hoza, 1996; Pelham et al., .57 rules) = .65 to in multiple
2001; Pelham et al., 2005; .89 across sites studies
Pelham et al., 2000) in MTA
Individualized target behavior α = .77 to .88 r (even days, odd Not reported Not reported Discriminates between r (ITBE, Teacher I/O) = .58 Sensitive to
evaluation (ITBE; Pelham, days) = .62 different treatment to .74. r (ITBE, Teacher behavioral and
unpublished data; Pelham manipulations (e.g., O/D) = .51 to .72. r (ITBE, pharmacological
et al., 2001; Pelham et al., medicated versus Counselor I/O) = .51. r treatment effects
2002; Pelham et al., in unmedicated days) (ITBE, Counselor O/D) = in multiple
press) .64. r (ITBE, STP Point studies
system measures) = .47 to
.84.

Note: DSM–IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; APA, 1994); ADHD = Attention-deficit/hyperactivity disorder; T = Teacher; P = Parent; Y = Youth; H/I = Hyperactive–Impulsive; I = Inatten-
tive; TRF = Teacher Report Form; CBCL = Child Behavior Checklist; I/O = Inattentive/Overactive IOWA Conners factor; O/D = Oppositional/Defiant IOWA Conners factor; GAF = Global Assessment of Functioning; STP =
Summer Treatment Program.
aThe table does not include an exhaustive review of measures or studies.
459
 PELHAM, FABIANO, MASSETTI
The Vanderbilt rating scale (Wolraich, Feurer, Hannah,
Baumgaertel, & Pinnock, 1998; Wolraich et al., 2003),
the current version of the Swanson, Nolan, and Pelham
Rating Scale, and the Child Symptom Inventory
(Sprafkin, Gadow, & Nolan, 2001) also include
comorbid symptoms of other disorders. Standardized
ADHD rating scales are currently recommended by the
American Medical Association (Goldman, Genel,
Bezman, & Slanetz, 1998), the AAP (2000), the Amer-
ican Academy of Child and Adolescent Psychiatry
(1997), and expert consensus (Lahey & Wilcutt, 2002).
Table 1 lists common ADHD rating scales. The
scales listed have parent and teacher versions (or are
appropriate for either rater). They are all clearly reli-
able. When intervention occurs in the interim, or the
interval lengthens, the stability of the scale scores is
less consistent. Cross-informant reliabilities are low,
ranging from .14 to .59, and show that raters differ in
their evaluations of ADHD behavior. The rating scales
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are effective at discriminating between clinical and
nonclinical groups (AAP, 2000) and among subgroups
of children with ADHD (e.g., Power et al., 1998).
Finally, these rating scales have a long history of use as
measures of treatment outcome and are clearly sensi-
tive to both behavioral and pharmacological treatment
effects (e.g., MTA Cooperative Group, 1999a).
Broadband Rating Scale Subscales
Broadband scales include items that span the range
of child psychopathologies and include both ratio-
nally- and empirically derived items. Although they
are not currently recommended for the diagnosis of
ADHD in clinical practice (AAP, 2000) because the
broad domain factors (e.g., externalizing) do not accu-
rately identify children with ADHD (Brown et al.,
2001), many studies have investigated the psycho-
metric properties of subscales of these measures in re-
lation to ADHD. The Child Behavior Checklist
(CBCL) and Teacher Report Form (Achenbach &
Rescorla, 2001) and the Behavior Assessment System
for Children (Reynolds & Kamphaus, 2002) are two
widely used broadband assessments. These scales dif-
fer in that the CBCL is empirically derived, whereas
the Behavior Assessment System for Children is ratio-
nally derived. A strength of the measures is that both
have detailed manuals that list normative information
across gender and developmental levels for many dis-
orders in addition to ADHD. Both scales include an
Attention Problems subscale (Achenbach & Rescorla,
2001; Edelbrock & Costello, 1988; Ostrander, Wein-
furt, Yarnold, & August, 1998), and such subscales are
frequently used as a proxy for ADHD diagnosis in re-
search studies (e.g., the Conduct Problems Prevention
Research Group, 2002; Hartman, Stage, & Webster-
Stratton, 2003). Other non-DSM–IV based ADHD rat-
ing scales include the Conners Parent and Teacher Rat-
460
ing Scales (Conners, Sitarenios, Parker, & Epstein,
1998a, 1998b), the Inattentive/Overactive factor of the
IOWA Conners Rating Scale (Loney & Milich, 1982),
and the Child Attention Problems Rating Scale
(Barkley, 1990; Edelbrock & Costello, 1988), which is
rationally derived from the Teacher Report Form.
Table 1 lists reliability and validity information on
these broadband subscales. The measures are highly
correlated with each other. Across days or months, the
subscales are also reliable. The Attention Problem
subscales on the broadband measures are also highly
related to DSM–IV diagnoses of ADHD. Ostrander et
al. (1998) reported that the Behavior Assessment Sys-
tem for Children correctly classified 97.7% of ADHD
cases diagnosed using the parent version of the Diag-
nostic Interview for Children and Adolescents (Boyle
et al., 1993). They further reported that the CBCL was
effective in identifying children with ADHD, primarily
inattentive type. Similarly, Chen, Faraone, Biederman,
and Tsuang (1994) found that the CBCL Attention
subscale was highly accurate in identifying children
with ADHD. It is important to note, however, that both
studies used a clinical sample with a high base rate of
ADHD, and these studies must be replicated in more
diverse samples.
The Conners Rating Scale and its short forms are
also well validated. When the Conners is compared
with other measures of symptoms (e.g., the Diagnostic
Interview Schedule for Children; Shaffer et al., 2000),
there is concurrent validity with correlations ranging
from .68 to .80. The IOWA Conners Rating Scale dif-
ferentially identifies children with hyperactive and ag-
gressive behavior (Loney & Milich, 1982), and it is
significantly related to objective measures of behavior
such as peer sociometrics and academic achievement
(Atkins, Pelham, & Licht, 1989). The Child Attention
Problems Rating Scale is useful for discriminating be-
tween children with inattention who have hyperactivity
and those who do not (Barkley, DuPaul, & McMurray,
1990).
Overall, these scales, using empirically or rationally
derived behavioral descriptors rather than explicit
DSM–IV symptoms, exhibit very good reliability and
validity. The measures are used ubiquitously for as-
sessing outcomes across childhood treatment outcome
studies (e.g., Barkley et al., 2000; Kolko et al., 1999;
Pelham et al., 1993) and are sensitive to both behavior
and pharmacological treatment effects.
Structured Interviews
Interviews (typically conducted with the child’s
mother) for the assessment of psychopathology in chil-
dren and adolescents have evolved primarily within
the context of research applications (Hodges, 1993).
Both epidemiological studies and other broad-based
research approaches have made extensive use of inter-
 ADHD ASSESSMENT
view methods for collecting diagnostic information
from large samples (Boyle et al., 1993; Shaffer et al.,
2000), and the use of structured interviews to assess for
diagnostic criteria is often required by grant and manu-
script reviewers. Interview questions are standardized
to reduce information variance, and multiple disorders
can be assessed with the same instrument. The use of
structured or semistructured interviews is recom-
mended by experts as part of ADHD assessments
(Lahey & Wilcutt, 2002).
Table 1 provides reliability and validity data on the
ADHD module of two common structured interviews
and two semistructured interviews. Reliability scores
for the Diagnostic Interview for Children and Adoles-
cents–Revised (Boyle et al., 1993; Reich, Shayka, &
Taibleson, 1991) and the Diagnostic Interview Sched-
ule for Children (Shaffer et al., 2000) are high for the
parent versions; the internal consistency and test–retest
reliability coefficients range from .60 to .90. Parent as-
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sessments of ADHD tend to be more reliable for older
children (Boyle et al., 1993). Stability of diagnosis has
been demonstrated over 1 to 3 years for both the Diag-
nostic Interview Schedule for Children and the Diag-
nostic Interview for Children and Adolescents–Re-
vised. It is further important to note that test–retest
reliability information for structured interviews is
largely based on clinic-based populations rather than
general population samples (Bravo et al., 2001; Jensen
et al., 1995; Shaffer et al., 1988; Sylvester, Hyde, &
Reichler, 1987). Consistent with the absence of valid-
ity of child reports of ADHD, agreement between par-
ents and children is quite low (kappas for the Diagnos-
tic Interview for Children and Adolescents–Revised
between .01 and .34).
The semistructured interviews we reviewed, the
Kiddie Schedule for Affective Disorders and Schizo-
phrenia (Orvaschel, 1985) and Child and Adolescent
Psychiatric Assessment (Angold & Costello, 2000),
have not published reliability data for children with
ADHD. Although internal consistency and test–retest
reliability information reported for other disorders is
moderate to strong, it is not possible to generalize these
findings to ADHD, especially given variability across
diagnostic categories found with other measures
(Jensen et al., 1996; Schwab-Stone et al., 1996).
Interview measures have some validity with respect
to diagnostic classifications (Angold & Costello, 2000;
Boyle et al., 1993; Carlson & Rapport, 1989; Lewczyk,
Garland, Hurlburt, Gearity, & Hough, 2003; Reich,
Shayka, & Taibleson, 1991). With respect to diagnostic
categories, classifications demonstrate both sensitivity
and specificity, indicating strong convergent and dis-
criminant validity. Relatively little information is
available with respect to concurrent validity, as rating
scales or other measures are not frequently compared
to interviews in diagnostic batteries. Available reports
do suggest concurrent validity (e.g., the parent Van-
derbilt rating scale and Diagnostic Interview Schedule
for Children–Version 4 correlation = .79; Wolraich et
al., 2003).
Measures of Impairment
Evaluation of impairment is typically conducted by
a clinician rating the child’s current level of function-
ing based on information collected during an intake
(e.g., clinical interview, parent and teacher ratings, re-
view of records) or by having the parent or teacher rate
impairment directly. As noted previously, there are nu-
merous methods currently used to evaluate psycho-
social impairment in specific domains of functioning.
Measures that document global or overall impairment
(e.g., the Children’s Global Assessment of Func-
tioning; Bird et al., 1990) or provide a multidimen-
sional assessment of impairment (e.g., the Child and
Adolescent Functional Assessment Scale; Hodges &
Wong, 1996) are also commonly employed. The re-
view of all measures of domain-specific impairment
would comprise its own article; we therefore limit our
review to global and multidimensional impairment
measures that have been used with ADHD samples
(Table 1).
The impairment ratings reviewed show good tem-
poral stability and interrater reliability, and there is evi-
dence of concurrent and convergent validity. In addi-
tion, the scales are highly efficient in classifying
clinical and nonclinical cases. The Child and Adoles-
cent Functional Assessment Scale (Hodges, Dou-
cette-Gates, & Liao, 1999; Hodges & Wong, 1996) and
the Children’s Global Assessment of Functioning
(Shaffer et al., 1983) are slightly different in content
and domains assessed, but both are clinician-com-
pleted and exhibit good psychometric properties. The
Columbia Impairment Rating (Bird et al., 1993, 1996),
the Impairment Rating Scale (IRS; Fabiano et al.,
2005), and the Vanderbilt (Wolraich et al., 2003) ask
parents to rate the child’s level of impairment, and all
scales evidence adequate reliability and validity. The
IRS and the Vanderbilt have teacher versions, which
also exhibit adequate psychometric properties. Thus,
for impairment ratings completed by clinicians, par-
ents, and teachers, there is substantial evidence for the
validity of measures.
Although these global impairment ratings are effec-
tive in identifying impaired areas of functioning, they
have not yet been widely used as measures of treatment
outcome. Impairment is typically measured using dis-
crete measures of individual domains of impairment
rather than global functioning measures or measures of
global functioning within specific domains (e.g., MTA
Cooperative Group, 1999a, 1999b). The information in
Table 1 suggests that any one of the global impairment
ratings may be a viable alternative to such multimea-
sure approaches, as the global measures correlate fa-
461
 PELHAM, FABIANO, MASSETTI
vorably with more extensive, domain-specific mea-
sures but are much shorter and less costly. Clinicians in
applied settings may find impairment measures that in-
clude domain-specific indexes of impairment (e.g.,
Child and Adolescent Functional Assessment Scale or
the IRS) more useful than those with a single global
rating (e.g., Children’s Global Assessment of Func-
tioning) because such measures can yield information
on key impaired functional domains that should be tar-
geted in further assessment and treatment.
Observational Measures
There is a long tradition of using behavioral obser-
vations with children described as disruptive, conduct
disordered, and hyperactive (M. W. Roberts, 2001). In
Table 1 we have listed a heterogeneous grouping of
observational methods. Five of the measures involve
having an independent observer evaluate the child’s
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behavior in an analog (e.g., clinic) or natural (i.e.,
classroom) setting to code the presence of behaviors
such as time on task, out-of-seat behavior, and verbal
intrusion (Abikoff, Gittelman-Klein, & Klein, 1977,
1980; Atkins et al., 1985; Atkins, Pelham, & Licht,
1988; Atkins et al., 1989; Barkley, 1990; Mash, Terdal,
& Anderson, 1973; Milich, Loney, & Landau, 1982).
In both clinical settings (e.g., Mash & Johnston,
1982; Milich et al., 1982) and natural settings (e.g.,
Abikoff et al., 1977; Atkins et al., 1985), the observa-
tional codes listed in Table 1 exhibit acceptable reliabil-
ity and validity. In addition, there are numerous
examples of these or similar observational systems dis-
criminating between ADHD and comparison children
and subgroups of ADHD children, as well as evidence of
sensitivity to the effects of behavioral and phar-
macological treatment (e.g., Abramowitz, Eckstrand,
O’Leary, & Dulcan, 1992; Chronis et al., 2004; Fabiano
et al., 2004; Klein & Abikoff, 1997; Murphy, Pelham, &
Lang, 1992; Northup et al., 1999; Pelham et al., 1993;
Pelham et al., 2000; Pelham, Greiner, & Gnagy, 1998;
Pelham, Wheeler, & Chronis, 1998; Rapport, Murphy,
& Bailey, 1982).
The Individualized Target Behavior Evaluation
(ITBE) is a very simple observational scheme that uses
teacher- or parent-implemented frequency counts as
proxies for more extensive observations by independ-
ent observers. It thus does not require a high degree of
training, a special setting, or independent observers.
Idiosyncratic problem behavior ratings have long been
used and have demonstrated sensitivity to treatment
(e.g., Patterson, 1974; Pelham, Schnedler, Bologna, &
Contreras, 1980). Such ratings and the ITBE are differ-
ent from a standardized problem behavior checklist be-
cause they include only the categories of behavior rele-
vant for a particular child. However, the former are
parent and teacher ratings, whereas the ITBE is a mea-
sure of whether a collection of events has occurred. An
462
ITBE operationalizes the idiosyncratic target behav-
iors within the child’s areas of impairment and sets a
criterion for each behavior evaluated (e.g., interrupts
three or fewer times during dinner; has no instances of
aggression during recess). The teacher or parent evalu-
ates whether the child has met each behavioral goal in
the time specified (e.g., during each class period), and
the overall percentage of targets met is calculated (e.g.,
65% of the goals were met on a given day). In clinical
use, the ITBE has been most widely used as part of a
daily report card in the school setting (e.g., O’Leary,
Pelham, Rosenbaum, & Price, 1976).
The psychometric properties of the ITBE are also
listed in Table 1 (Pelham et al., 2001; Pelham et al.,
in press). The ITBE is reliable, with internal consis-
tency coefficients ranging from .77-.88, and accept-
able temporal stability. The ITBE also correlates
moderately to highly with standard paper-and-pencil
measures of ADHD behavior (i.e., IOWA Conners
subscales) and with observational measures. In addi-
tion, it is an idiographic measure of treatment out-
come that is sensitive to the effects of medication and
behavior modification (e.g., Chronis et al., 2004; Pel-
ham, Burrows-MacLean, et al., 2005; Pelham et al.,
2001; Pelham et al., 2002).
Advantages and Limitations
of Current Assessment Methods
Given that the psychometric properties of all of the
methods reviewed here are sound, our consideration of
the advantages and limitations of each method empha-
sizes the utility of the approach. Considering first rating
scales as a group, characteristics that likely contribute to
their ubiquitous use include that they are easy to admin-
ister and score, take little rater or clinician time, and are
cost-efficient, allowing the clinician to obtain informa-
tion from multiple raters across settings. They have be-
come the sine qua non of methods for diagnosing
ADHD. Limitations of ADHD-specific rating scales in-
clude a lack of information regarding impairment (but
see Waschbusch, Sparkes, & Northern Partners in Ac-
tion for Child and Youth Services, 2003, and Wolraich et
al., 1998, 2003, for exceptions), thus requiring the ad-
ministration of additional measures. These limitations
could be dealt with by adding sections to current
ADHD-specific rating scales similar to the first section
of the CBCL or the last section of the Vanderbilt. The
scales also typically do not assess for other important di-
agnostic information such as age of onset or chronicity
of the symptoms. Again, this limitation could be reme-
died by including the relevant questions. Rating scales
may also be insensitive to low base rate or covert behav-
iors that may be underestimated or unknown to the rater
and can be better assessed through an observational sys-
tem or nonobtrusive measures (see Fabiano et al., 2004;
Hinshaw, Simmel, & Heller, 1995, for examples). Al-
 ADHD ASSESSMENT
though the standardized symptom rating scales are
psychometrically sound and sensitive to treatment ef-
fects, the DSM–IV symptoms of ADHD themselves are
poor descriptors of clinically important treatment out-
comes (i.e., social validity; Foster & Mash, 1999; Pel-
ham & Fabiano, 2001) and have limited treatment utility
(Scotti, Morris, McNeil, & Hawkins, 1996) and predic-
tive validity (Mannuzza & Klein, 1999; Pelham, Lahey,
Gnagy, Kipp, & Roy, 2005).
Finally, there is the possibility of bias in parent rat-
ings of ADHD. For example, maternal depression is
common in families that include a child with ADHD,
and it has been argued that parental depression may in-
fluence ratings (Chi & Hinshaw, 2002), making chil-
dren appear to have ADHD even though they do not.
On the other hand, if mothers have a history of depres-
sion but are not actively depressed, bias may not be an
issue (Baumann, Pelham, Lang, Jacob, & Blumenthal,
2004). The clear implication for both researchers and
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clinicians is that evaluations from teachers or other
sources (observations) are needed in addition to par-
ents. There are few studies on this topic, and more are
needed across multiple parental characteristics.
Although they are valid for initial screening and
identifying ADHD cases, structured interviews may be
impractical for situations where repeated measure-
ments are required and for measuring specific domains
of impairment. Structured interviews require a signifi-
cant amount of clinician or parent time, making them
too costly for use in most clinical settings. Computer
administration can reduce staff time, but it also reduces
structured interviews to the same information set as
rating scales (e.g., a yes/no check on a computer versus
a paper form), eliminating a putative advantage of in-
terviews. In addition, if structured interviews with par-
ents are administered without the concurrent adminis-
tration of teacher ratings, critical information on the
child’s functioning in the school setting will be lost.
Despite their costs, as well as the fact that they have not
been validated against direct observations or objective
records, DSM–IV-based structured interviews have
been accepted by many as the gold standard in psy-
chology and psychiatry.
Global impairment ratings are efficient, well-vali-
dated measures for obtaining information on the de-
gree to which the child is experiencing problems in
daily life functioning. Advantages of these measures
include their ease of administration and scoring. Multi-
dimensional measures of impairment such as the IRS
and the Child and Adolescent Functional Assessment
Scale provide domain-specific information on func-
tioning as well as an overall global rating. Such multi-
dimensional ratings can be conceptualized as the fo-
cused global ratings suggested by Mash and Foster
(2001) to simplify more complex assessment schemes.
In contrast, non-domain-specific ratings of impairment
(e.g., the Children’s Global Assessment of Func-
tioning) have limited treatment utility; a clinician who
collects such a rating would then have to follow up
with questions about functioning across specific do-
mains of impairment to plan effectively for treatment.
Observational measures may yield objective infor-
mation that is often viewed as the gold standard in re-
search, particularly as measures of treatment effects.
However, traditional observational measures have lim-
itations, particularly for clinical application, including
high cost, the need to train observers, and the need to
conduct multiple ratings across days and settings to ob-
tain stable and representative estimates of behavior.
The observational codes all use a time-sampling ap-
proach or an analog situation (e.g., parent–child inter-
actions in a clinic) as a proxy for behavior in natural
settings. Time sampling is problematic because it is
difficult to measure low base rate behaviors (e.g., ag-
gression). Observations in clinic analogue settings are
costly and difficult to employ in clinical practice, and
they do not provide a representative example of the
child’s behavior in the natural environment (e.g., Mash
& Foster, 2001; M. W. Roberts, 2001). Finally, even
gathering on-task information through observations
may be less efficient than employing nonobtrusive
measures such as asking teachers to track how much
class work the child produced. Because observations
of on-task behavior are a proxy for how productive the
child is in the classroom, Atkins and colleagues (1985,
1988, 1989) had teachers save children’s assignments
and scored their completion and accuracy, and this
measure contributed to a discriminant function that
separated ADHD and control children. Such measures
have also been widely used in both regular school and
analogue classroom settings to evaluate treatment ef-
fects (e.g., Pelham et al., 1993). Atkins and colleagues
also checked children’s desks once per day and evalu-
ated whether the child was prepared for class (e.g., had
pencil and eraser in desk). Not only did these unobtru-
sive measures cost little and discriminate accurately,
but they also constitute logical targets for intervention
and can be easily monitored to evaluate improvement.
A common thread in commentaries on assessments
for child disruptive behavior disorders concerns the
importance of identifying measures not only with an
evidence base, but also with a high degree of utility in
clinical settings (Nelson-Gray, 2003), where time-in-
tensive and therefore expensive measures such as
structured diagnostic interviews and behavioral obser-
vations are not viewed as practical or cost-effective and
are not routinely used (Mash & Foster, 2001; Meyer et
al., 2001; Mori & Armendariz, 2001; M. W. Roberts,
2001). The ITBE may provide a solution to this di-
lemma. It is best conceptualized as a combination of a
simple objective observation and behavioral rating of
impaired areas of functioning that addresses many of
the limitations inherent in other assessment measures.
First, it is an idiographic measure of functioning; in-
463
 PELHAM, FABIANO, MASSETTI
stead of asking parents or teachers to complete lengthy
rating scales, or observers to code for numerous behav-
iors, the ITBE only includes target behaviors relevant
to the particular child being observed. Second, the
ITBE provides continuity throughout clinical contact
with a child across both time and settings (e.g., home,
school, peer and recreational). Third, the ITBE is par-
ticularly useful for low base-rate behaviors (e.g., steal-
ing, fighting) because it is more likely to code behav-
iors than is a time-sample approach, and it can replace
observations of on-task behavior by targeting teacher-
recorded work completion as discussed earlier. Fourth,
measures such as the ITBE are parent recorded, teacher
recorded, or both, rather than observer or clinician re-
corded. This minimizes cost and maximizes parent and
teacher involvement in the assessment process. In ad-
dition, procedures for developing ITBEs (the target be-
havior operationalization in an FBA) are widely avail-
able in textbooks and on the Internet and do not involve
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expensive training or recurring costs for copyrighted
materials. Finally, the ITBE targets are the socially and
empirically valid targets of treatment—the problem-
atic behaviors for which the child is initially referred
and therefore the natural targets of intervention (Foster
& Mash, 1999; Pelham & Fabiano, 2001). In the case
of behavioral intervention, the ITBE constructed dur-
ing assessment becomes the daily report card that is the
backbone of clinical behavior therapy for a child with
ADHD (O’Leary et al., 1976). The target behaviors it
contains are the focus of intervention and are moni-
tored continuously to evaluate progress during treat-
ment, seamlessly connecting initial assessment, treat-
ment, and outcome monitoring. The ITBE is another
example of a measure that approximates Mash and
Foster’s (2001) suggestion for simplified observational
schemes that have focused global ratings.
All of the assessment methods we have reviewed
have the limitation of shared method and source var-
iance. Psychometricians have long known that the
source of ratings and method of measurement contrib-
ute a significant portion of the variance in correlations
between measures and criteria (e.g., Campbell &
Fiske, 1959; Gomez, Burns, Walsh, & de Moura, 2003;
Langhorne, Loney, Paternite, & Bechtoldt, 1976;
Meyer et al., 2001). This is illustrated in correlations
between the Attention Problems subscale of the
Teacher Report Form and the teacher Conners (r = .80).
However, the high degree of shared variance appears to
be limited to situations where the same rater uses the
same method (see Table 1). Shared variance is far more
modest in measures using different sources or methods
(Achenbach, McConaughy, & Howell, 1987; De Los
Reyes & Kazdin, 2004; Langhorne et al., 1976; Meyer
et al., 2001).
Cross-informant agreement with rating scales is ex-
pected to be low because (a) raters have different toler-
ances for and interpretations of a child’s behavior and
464
(b) children behave differently across situations and
therefore informants typically have access to nonover-
lapping information. The implication for assessment is
clear: Raters from a single source or setting do not pro-
vide a comprehensive picture of the current levels of
functioning for a child with ADHD—ratings from both
parents and teachers are always indicated for compre-
hensive ADHD assessment (see also Meyer et al.,
2001; Power, Costigan, Leff, Eiraldi, & Landau, 2001).
Nearly all the studies included used school-age,
Caucasian boys as participants. Converging evidence
suggests that normative ratings for boys and girls on
these rating scales are different, with boys’ average rat-
ings being more deviant than girls’ ratings in clinical
and community samples (e.g., DuPaul, 1991; Fabiano
et al., in press; Newcorn et al., 2001; Pelham, Milich,
Murphy, & Murphy, 1989); some authors thus report
normative information by gender (e.g., Achenbach &
Rescorla, 2001). However, even studies such as the
DSM–IV field trial included 76% boys, making it un-
clear whether the girls included in the study are repre-
sentative of all the girls in the population with ADHD
or whether they represent only the severe end of the
continuum of ADHD in girls (Frick et al., 1994). Be-
cause the ADHD literature to date focuses mostly on
boys, more research in this area is needed.
Another understudied area is the impact of racial
and ethnic differences on the measurement of ADHD.
It is difficult to draw conclusions regarding the extent
of differences between groups given the few number of
studies that report normative information by racial or
ethnic group (e.g., Samuel et al., 1997). Studies that
have explicitly investigated racial or ethnic differences
on standardized rating scales are suggestive of differ-
ences between groups (e.g., Epstein, March, Conners,
& Jackson, 1998; Epstein et al., in press; Reid, Casat,
Norton, Anastopoulos, & Temple, 2001; Reid et al.,
1998), with African American children generally rated
with higher scores than European American children.
These results indicate that ethnically and culturally ap-
propriate norms should be utilized in assessments and
screenings to prevent a high rate of false positive iden-
tifications of African American children. Beyond these
studies, little information is available on other racial or
ethnic groups, and more research in this area is needed.
Similarly, raters with lower verbal functioning, such as
mothers with lower educational attainment, may have
substantial difficulties with the language used in rat-
ings, and these measures have not been validated with
such populations.
Finally, most ADHD measures are validated in sam-
ples of school-age children. With the recent profes-
sional consensus conceptualizing ADHD as a chronic
disorder (AAP, 2001), measures of preschool-age chil-
dren, adolescents, and adults with ADHD are needed.
Broadband measures currently include factor and nor-
mative information for preschoolers and adolescents
 ADHD ASSESSMENT
(Achenbach & Rescorla, 2001; Reynolds & Kamp-
haus, 2002); however, we are aware of only one study
of the validity of parent and teacher ADHD-specific
rating scales and a structured interview in preschool
children (Lahey et al., 1998). At this time, the avail-
ability of well-validated ADHD measures for young
children is limited. For example, although the DSM–IV
diagnosis appears to accurately identify preschoolers
with the impairments and symptoms characteristic of
older ADHD children (Lahey et al., 1998), it is difficult
to adhere to DSM–IV criteria, which mandate cross-sit-
uational impairment, for children who are not in a
structured school setting. A few studies have validated
or explored the usefulness of ADHD measures in ado-
lescents and concluded that the two-factor structure
of inattentive and hyperactive–impulsive symptoms is
consistent with that obtained in childhood (Conners et
al., 1998a, 1998b; Molina, Smith, & Pelham, 2001). In
addition, consistent with studies of school-age chil-
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dren, studies of adolescent self-report indicate adoles-
cents are poor reporters of ADHD symptoms, provid-
ing no unique contribution beyond parent and teacher
ratings (Smith, Pelham, Gnagy, Molina, & Evans, 2000).
For both preschoolers and adolescents, few studies
have explicitly investigated whether the number of
symptoms needed for diagnosis differs depending on
age (as might be expected given the development of at-
tention and impulse control, but see Frick et al., 1994,
for a study that found few age differences). Areas in
need of further study include the incremental validity,
predictive power, and appropriateness of the current
DSM–IV criteria for preschoolers and adolescents.
Impairment ratings, in contrast, may be less influ-
enced by factors such as gender, race or ethnicity, or
age, and they are not constrained by DSM–IV criteria
(e.g., Angold et al., 1999; Fabiano et al., 2005). There-
fore, for clinical purposes—for example, deciding
about a need for treatment—emphasizing impairment
more than DSM–IV symptoms is a way to avoid mak-
ing erroneous decisions based on the paucity of data
for younger and older children and for girls and
non-Caucasian children. Overdiagnosis in preschool
and non-Caucasian children and underdiagnosis in ad-
olescents and girls could be minimized, with treatment
provided to children whose functional impairments
justify it.
Incremental Validity
Although the standard assessment techniques used
for ADHD have a clear evidence base (Table 1) when
used independently, an important question is: What are
the minimum strategies and tools necessary for an effi-
cient and effective assessment for ADHD? Central to
this question is the incremental validity of adding addi-
tional raters or methods to an initial strategy for assess-
ment. For example, if parent and teacher ratings are
taken as a standard start to assessment, a prudent deci-
sion given their reliability, validity, and cost efficiency,
this decision can take many forms, including (a)
whether a subset of items on a measure would be as ef-
fective as the full measure; (b) whether both parent and
teacher ratings provide incremental information, given
the other; (c) whether structured parent interviews pro-
vide additional information, given parent ratings; (d)
whether observational or laboratory methods provide
incremental information, given rating scales; (e)
whether comorbid diagnoses add incremental validity
to ADHD assessments; (f) whether assessment of
non-ADHD symptom domains of impairment adds
incrementally to assessment; and (g) whether FBAs
add incremental validity to parent and teacher diagnos-
tic rating scales. Interestingly, although these are cen-
tral questions in the assessment of ADHD, few studies
have explicitly explored these issues (Johnston & Mur-
ray, 2003).
In discussing the incremental validity of assessment
measures, we use standardized DSM–IV rating scales
as a standard. DSM–IV symptom-based rating scales
are lengthy (ranging from 18 to more than 100 items)
and therefore somewhat difficult for teachers to com-
plete. This is especially true if the CBCL is also being
administered to screen for additional disorders. Small-
er item sets reduce assessment cost and make large-
scale screenings and clinical assessments more feasi-
ble, particularly in school settings. A relevant question,
therefore, is whether incremental validity is improved
by using all of the DSM–IV items rather than a small
subset.
Some researchers have investigated the utility of
single DSM–IV items or item combinations to either
identify children with ADHD or rule out those without
the disorder (Frick et al., 1994; Milich et al., 1987; Pel-
ham, Gnagy, et al., 1992; Power, Andrews, et al., 1998;
Power et al., 2001; Power, Doherty, et al., 1998). As
Power et al. cogently note, the DSM–IV items have dif-
fering predictive powers, yet the DSM–IV weights all
symptoms equally. Certainly identifying the symptoms
with the greatest predictive power would allow for
more efficient, less costly assessments. An item’s abil-
ity to identify a child with ADHD is typically assessed
by calculating the item’s positive predictive power
(PPP), whereas an item’s ability to identify a child
without ADHD is assessed via its negative predictive
power (NPP). The researchers cited earlier have exam-
ined PPP and NPP of individual DSM–IV symptoms
and have found that one or two ADHD symptoms (e.g.,
one inattention item and one impulsivity item) may be
useful for either identifying ADHD cases or children
appropriate for further screening or ruling out children
who should not be subjected to further screening. Un-
fortunately, no studies of which we are aware have cre-
ated a brief scale from the items that appear to have
high PPP and NPP to examine its ability to discrimi-
465
 PELHAM, FABIANO, MASSETTI
nate between ADHD and comparison samples. Across
the studies described previously, items with high PPP
generally had low base rates. That is, the symptoms
were rare but, if endorsed, it was very likely that the
child was identified as ADHD. In contrast, the items
with high NPP generally had higher base rates. Thus, if
the more common behavior was not endorsed, it was
very unlikely the child would be identified as an
ADHD case. However, the impact of base rates on
identification of ADHD cases has not been widely
studied. For example, in a clinical setting, where fre-
quent reports of ADHD symptoms are expected, cut
points on measures may need to be different than in a
whole-school sample, where ADHD symptoms may
be relatively less common.
Power, Andrews, et al. (1998) and Power, Doherty
et al. (1998) have also investigated the incremental va-
lidity of multiple raters and the number of items re-
quired by each rater or combinations of raters to effi-
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ciently identify children with ADHD (Power et al.,
2001). They demonstrated that, when combined, par-
ent and teacher items with the greatest PPPs are highly
effective in identifying ADHD cases. In fact, for ruling
out cases of ADHD, two informants were not necessar-
ily required; if either the parent or teacher did not en-
dorse an item with a high NPP, the child was usually a
child without ADHD. There has been relatively little
research on the need for both parent and teacher raters
and how best to combine them. We argue in the follow-
ing that for treatment purposes both are necessary, but
whether both are necessary for diagnosis is a question
worthy of additional research.
An alternative to searching for a subset of DSM–IV
items that predict diagnosis is to examine whether in-
cremental validity is added by the longer DSM–IV-
-based scales compared to briefer, empirically derived
scales. Not surprisingly, because the empirically de-
rived scales were used long before DSM–IV and were
the basis for most of the DSM–IV items, there is a con-
siderable amount of overlap among item content, and
they are highly correlated (Table 1). The five items that
comprise the Inattentive/Overactive scale on the IOWA
Conners were developed from and are highly associ-
ated with longer sets of items on the full Conners Rat-
ing Scales (Conners, 1969; Loney & Milich, 1982).
The 10-item IOWA is equally sensitive to treatment ef-
fects and group comparisons compared to longer sets
of items such as the 45-item, DSM–IV-based Disrup-
tive Behavior Disorders rating scale. Similarly, the
Child Attention Problems Rating Scale (cf. Barkley,
1990) is highly related to DSM–IV-based rating scales
at only two thirds the length (i.e., Power et al., 1998).
This literature contrasts with the assessment recom-
mendations of the AAP, which emphasize using
DSM–IV criteria and obtaining information on those
criteria from parents and teachers and include a
466
DSM–IV symptom-based scale in their Toolkit for
ADHD (American Academy of Pediatrics and Na-
tional Initiative for Children’s Healthcare Quality,
2002); the guidelines do not recommend the use of em-
pirically derived, non-DSM–IV based scales in diagno-
sis (AAP, 2000). Further, the AAP guidelines state that
parent or teacher rating scales are an option, not a re-
quirement, in making the DSM–IV diagnosis. This rec-
ommendation appears to need qualification, as the cur-
rent literature supports the use of ADHD subscales
on broadband measures in classifying children with
ADHD.
A key question from the view of cost of services is
whether structured interviews provide incremental di-
agnostic validity beyond parent and teacher rating
scales. There has been relatively little research on this
point—most researchers use both structured inter-
views and rating scales. The existing research suggests
that no incremental validity is conferred from the use
of structured interviews. Table 1 indicates that rating
scales correlate with structured parent interviews. Fur-
thermore, groups of children identified by structured
interviews are also nearly perfectly classified using
symptom rating scales (e.g., DuPaul, Power, McGoey,
Ikeda, & Anastopoulos, 1998; Ostrander et al., 1998;
Power et al., 2001). There is no evidence that combin-
ing rating scales with structured interviews will result
in incremental benefit for diagnosis of ADHD (e.g.,
Wolraich et al., 2003). These results contradict the uni-
versal recommendation to researchers and clinicians
that structured interviews are necessary for diagnosis
and suggest that substantial savings in diagnostic costs
could be obtained by relying more on rating scales.
Whether direct observations provide incremen-
tal validity above parent and teacher ratings is also an
important question. We are not aware of any research
on the incremental diagnostic validity of observation-
al schemes for diagnosis; however, we can address
whether an entire complex observational scheme must
be used or if a subset of codes is adequate. There is evi-
dence that verbally intrusive behaviors in the class-
room are the best predictors of ADHD status, with
other categories providing little incremental validity
(Abikoff et al., 1977, 1980; Atkins et al., 1985, 1989).
This result suggests that if a teacher or aide reliably
recorded instances of verbally intrusive behavior
(e.g., completed via the ITBE as a target behavior),
complex observational measures and the expense of
an independent observer could be eliminated. This
key behavior could be targeted in treatment and moni-
tored as a socially and empirically validated index of
treatment response. Similarly, Atkins et al. (1985)
showed that routine teacher-recorded seatwork com-
pletion and accuracy discriminated between ADHD
and comparison cases better than observations of
on-task behavior.
 ADHD ASSESSMENT
Interestingly, direct observations are the gold stan-
dard for evaluating treatment effects in controlled tri-
als. Because the observational schemes in Table 1 cor-
relate only modestly with parent and teacher ratings,
they clearly provide unique information for these pur-
poses (e.g., Atkins et al., 1989). In studies of treatment
outcome, observational measures have revealed pat-
terns of results that are not apparent when ratings alone
are obtained and therefore provide incremental validity
in assessing treatment effects. Further, direct obser-
vations avoid the biases that are inherent in rating
scales—especially in treatment studies in which rater-
blinding is not possible or is easily compromised.
A related point can be made about laboratory mea-
sures of attention and impulsivity. Even though we
have not discussed these measures because it is widely
agreed that they are not valid for the purpose of diagno-
sis (AAP, 2000) or measuring ecologically valid treat-
ment response (e.g., Nigg, Hinshaw, & Halperin,
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1996), cognitive performance cannot be well studied
with any other method. Thus, there is a role to play for
laboratory measures in research with the goal of under-
standing the nature of cognition in ADHD, despite the
fact that laboratory measures do not contribute to diag-
nosis or clinical assessment.
Is there evidence that incremental validity is gained
by assessing comorbid diagnoses? Although empha-
sized in research and practice, as we discussed at the
beginning of this article, there is little research show-
ing that information regarding comorbidity influences
the utility of assessment in ADHD. The few studies ad-
dressing this point show that comorbid diagnoses do
not influence response to treatment and therefore treat-
ment planning (e.g., MTA Cooperative Group, 1999b;
Pelham et al., 1993). The approach to and evaluation of
treatment for ADHD-related problems are identical:
pharmacological or behavioral treatment or both. This
is true even when the decision is whether a child
meets full ADHD criteria or has a subthreshold num-
ber of symptoms. When this situation exists in med-
icine or psychopathology, diagnoses—both primary
and comorbid—have no treatment utility and should
be made as efficiently and cost-effectively as possi-
ble (Meyer et al., 2001; Nelson-Gray, 2003; Pelham,
2001). Target behaviors may be added when a child has
a comorbid diagnosis (e.g., peer-directed aggression),
but that information comes from assessment of impair-
ment in key domains rather than from the comorbid
diagnosis.
Impaired functioning is required for ADHD diagno-
sis and must be assessed, but is there evidence that it
adds incremental validity? Because the correlation be-
tween ADHD symptoms and impairment is modest
(Fabiano et al., 2005), because there is variability in ex-
pression of ADHD-related impairment across domains
(Lahey et al., 1998), and because measures of impair-
ment and symptoms account for unique variance in
predicting outcomes (Pelham, Lahey, et al., 2005), it is
clear that measures of impairment add incremental va-
lidity beyond an ADHD diagnosis. How comprehen-
sive such assessments need to be is another question.
Consider the MTA study, which employed a broad set
of assessment instruments to capture the baseline func-
tioning and treatment outcomes of the children treated
in that study (Hinshaw et al., 1997). For treatment out-
come in particular, different domains and methods of
assessment yielded outcomes for the four treatment
conditions that were very different from the parent and
teacher Swanson, Nolan, and Pelham Rating Scale
DSM–IV symptom ratings (MTA Cooperative Group,
1999a). For example, there was no effect of stimulant
medication on academic achievement but a large effect
on parent and teacher ratings. At follow-up, behavioral
and pharmacological treatments differed on adult-
rated DSM–IV symptoms but not in any key functional
domain (achievement, peer relations, parenting; MTA
Cooperative Group, 2004). A secondary outcome ar-
ticle involved combining all of the measures into a
single scale and yielded stronger evidence of psycho-
social and combined treatment effects, relative to
medication, than any other set of analyses (Conners
et al., 2001). Although unique information was ob-
tained regarding treatment effects employing multi-
ple-outcome domains, the MTA group did not conduct
a systematic study of which outcome variables contrib-
uted unique variance to evaluation of treatment effec-
tiveness. We are not aware of any study that has con-
ducted such an evaluation, and one is needed, as the
incremental validity or treatment utility of large sets of
outcome measures for both research and clinical prac-
tice has not been well studied. Further, our previous
discussion of measures of impairment argued that in-
expensive, simple domain-specific measures of im-
pairment (e.g., IRS, CBCL) are sufficiently highly cor-
related with more comprehensive measures (e.g.,
achievement) that they can be used instead at very large
cost savings.
Finally, will incremental validity be gained beyond
parent and teacher rating scales by conducting FBAs
that focus on functioning rather than DSM–IV symp-
toms of ADHD? In other words, is there value beyond
identifying key domains of impairment in conducting
assessments that evaluate the contexts in which the
problems occur with a focus on setting events and
maintaining variables—all focused on case conceptu-
alization and treatment planning (Gresham et al.,
2001)? Surprisingly, relatively little research has ad-
dressed this question either for ADHD or in general
(Ervin et al., 2001), and more research is needed. At a
clinical level, however, conducting such an assessment
has clear face validity—other than pharmacological in-
terventions, an evidence-based treatment for ADHD
467
 PELHAM, FABIANO, MASSETTI
(all of which are behavioral) could not be developed
for a child with ADHD without conducting an FBA.
Implications for Clinical Practice
Our review has clear implications for clinical prac-
tice. Effective screenings for ADHD may be made
quickly and economically using only a few items com-
pleted by parent and teacher respondents (e.g., August
et al., 1996). Across studies and measures, brief mea-
sures such as the Inattentive/Overactive scale of the
IOWA Conners, the Child Attention Problems Rating
Scale, individual and pairs of DSM–IV items both
within and across raters, and the Behavior Assessment
System for Children Attention Problems subscale
all reliably classify children diagnosed with ADHD.
Lengthy and expensive structured interviews and com-
plete DSM–IV-symptom-based rating scales add little
incremental information in formulating an ADHD di-
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agnosis; and a few observational measures are as use-
ful as complete complex observation systems for ef-
fectively discriminating ADHD from comparison
children. A brief rating scale or a combination of a
small number of DSM–IV items from parent and
teacher ratings, ITBE records of verbal intrusion, rou-
tine teacher records of seatwork completion and accu-
racy, and nonobtrusive evaluations of whether the child
has the required supplies in his or her desk at school
would appear to be an efficient and parsimonious way
of diagnosing ADHD in clinical practice, with more
objectivity than rating scales alone but at a very low
cost relative to structured psychiatric interviews. The
kind of large-scale research needed to validate this ap-
proach to assessment has not yet been conducted, but
clinicians can be confident based on extant research
that it has some empirical support.
Such an approach would have considerable treat-
ment utility because it would be feasible and cost-ef-
fective in primary care and educational settings, where
training in mental health assessment is limited and cost
and time issues are paramount. Less time spent on
making a diagnosis leaves the clinician, physician, or
school counselor with more time to focus on treatment.
Once a diagnosis is established, the clinician needs to
conduct the rest of the assessment process, including
(a) identifying impaired domains of functioning;
(b) operationalizing target behaviors within these do-
mains; (c) conducting a functional analysis of the an-
tecedents, settings, and consequences of the target
behavior(s); and (d) implementing treatment and con-
structing measures such as the ITBE to monitor and
evaluate treatment progress. In other words, after diag-
nosis, all assessment focuses on the child’s specific im-
paired areas of functioning or target behaviors and the
treatment of these behaviors—not DSM–IV symptoms.
Consider, for example, the symptom “often does not
seem to listen when spoken to directly.” A child who
468
has this item endorsed on a structured interview or rat-
ing scale would have the item count toward a diagnosis
of ADHD. However, the item in and of itself provides
no information on the extent to which this behavior is a
problem for the child and what causes, maintains, or
exacerbates the behavior. For one child, the function of
the behavior could be to avoid tasks he or she dislikes
and is limited to situations where a demand is placed
on the child. For another child, the behavior may be
caused by poor adult commands and instructions that
fail to make the desired behavior clear to the child. A
third child may have a clear attention problem and may
not be processing the instructions. An FBA of the prob-
lematic behavior would result in three different treat-
ment approaches based on the three different hypothe-
sized functions (Gresham et al., 2001; Nelson-Gray,
2003). In other words, the symptom is not informative
for treatment without knowledge of the impaired func-
tioning that it reflects and its context.
Regarding the samples in which relatively less is
known about ADHD diagnosis (low socioeconomic
status, ethnicity, preschoolers, adolescents) a focus on
impairment and FBA should minimize the conse-
quences of potential diagnostic errors. If an African
American child or a preschooler is identified through
inappropriately elevated parent or teacher ratings of
DSM–IV symptoms, a careful determination of level of
impairment and a good FBA should discount the symp-
tom ratings if there truly is a false positive diagnosis.
The opposite problem could occur with a girl or an ad-
olescent—low symptom scores from teachers ruling
out the diagnosis but clear impairment documenting
a need for intervention. Thus, available instruments
should be used with caution in these samples with a fo-
cus on impairment rather than symptom levels.
This approach—deemphasizing the relative impor-
tance of a DSM–IV diagnosis and the traditional ap-
proaches to assessment and focusing instead on func-
tional behavioral analysis of impairment— may make
psychologists uneasy for several reasons. Some may
fear that reliance on simple parent and teacher rating
scales for diagnosis (as opposed to structured inter-
views and neuropsychological batteries) will increase
the number of children identified with ADHD and
therefore the number treated with medication. As we
noted previously, however, most children are referred
for treatment based on functioning in daily life rather
than symptoms. If the clinician’s focus is on functional
impairments and adaptive skills, children so identified
need treatment, and elevated rates of identification are
not a concern. If psychological practitioners increased
their collaboration with primary care physicians, who
prescribe most of the medication for ADHD, to imple-
ment established treatment guidelines (AAP, 2001),
such an outcome is neither inevitable nor likely.
Alternatively, some may be concerned that mini-
mizing the traditional role filled by psychologists (con-
 ADHD ASSESSMENT
ducting comprehensive, multi-instrument assessments
and integrating and interpreting diagnostic informa-
tion) might mean that psychologists’ roles in diagnosis
and treatment of ADHD will be diminished. To the
contrary, assigning a DSM–IV diagnosis has become
almost a cookbook activity that can be performed by
many different professionals. However, few if any pro-
fessionals other than psychologists are trained in pro-
cedures for conducting FBAs and employing the re-
sults to design and monitor treatment, and this unique
role is preserved in our approach. An emphasis on
functional outcomes rather than DSM–IV diagnosis
does not mean that professionals who adopt this ap-
proach will be less involved in assessment and treat-
ment of ADHD—only that they will spend their time
engaged in different activities.
Conclusions
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This review highlights the evidence for assessment
methods for children with ADHD but also reveals limi-
tations and clear directions for needed research. We
enumerate conclusions in the following that inform
practitioners and researchers on the evidence-based as-
sessment of ADHD.
1. Using traditional psychometric criteria, there is
substantial evidence for the reliability and validity of
many measures commonly used to diagnose ADHD
and measure treatment outcomes, including DSM–IV-
based as well as empirically and rationally derived
ADHD rating scales, DSM–IV-based structured inter-
views, measures of global impairment, and observa-
tional methods. These all exhibit the requisite reliabil-
ity and validity estimates needed for evidence-based
assessments. There is currently no evidence supporting
the validity of child self-report of ADHD symptoms.
Because virtually all use of rating scales and structured
interviews involves mother report, there is no evidence
on the validity of father report.
2. Diagnosing ADHD is most efficiently accom-
plished with parent and teacher rating scales. All three
forms of rating scales—DSM–IV based, rationally de-
rived, and empirically derived—are valid and agree
equally well with other methods of diagnosis. Because
rationally and empirically derived scales have fewer
ADHD items (e.g., the IOWA Conners) and often
screen for other disorders and impairments (e.g., the
CBCL), they are more efficient than DSM–IV-based
scales. There is evidence that only a few DSM–IV
items with high PPP or NPP, depending on the purpose
of the assessment, are as effective as complete symp-
tom lists, but measures using only these items have not
been systematically evaluated. The number of raters
needed to identify children with ADHD depends on the
purpose of the assessment. For large-scale screenings,
a single teacher rating with a few items that have high
NPP and PPP may be sufficient. However, because of
the modest agreement between parents and teachers,
because of the DSM–IV requirement for information
on cross-situational impairment, and because target
behavior identification and treatment planning is set-
ting-specific, information from both parents and teach-
ers is necessary for clinical purposes.
3. Symptom rating scales must be combined with a
clinical interview or additional paper-and-pencil ques-
tions to obtain information about onset and rule out
other disorders (e.g., low IQ, autism). However, DSM–
IV-based structured diagnostic interviews do not add
incremental validity to parent and teacher rating scales.
The current practice of requiring structured DSM–IV-
based interviews in an attempt to increase diagnostic
precision is not supported by research. There are few
studies examining incremental validity of other meth-
ods compared to rating scales.
4. Observational methods that include only a few
categories (e.g., verbal intrusions) and utilize a few
nonobtrusive measures (e.g., teacher-recorded work
completion) are as effective as more comprehensive
observations with multiple categories or aggregates
thereof for identifying children with ADHD and are far
more efficient. Additionally, there is growing evidence
that simple proxies for complex observations (e.g., tar-
get behavior probabilities) may be useful. Systematic
investigation of the incremental validity of such ap-
proaches added to rating scales is needed.
5. Systematic assessments for other disorders that
are comorbid with ADHD should follow guidelines in
other articles in this special section; however, it is
worth emphasizing that diagnostic information does
not inform one’s treatment approach regardless of the
ADHD-related diagnosis (e.g., subtype, comorbidity).
6. Because of the modest correlation between
ADHD symptoms and impaired functioning, assess-
ment of ADHD must include evaluation of the child’s
functioning in the key domains of peer and sibling and
parent and teacher relationships, academic progress,
and the classroom and family. There are numerous
measures available that have been validated for each of
these domains. Very brief assessments of those do-
mains may be sufficient for both research and clinical
purposes (i.e., those included on measures of global
impairment), but additional research is needed. Objec-
tive assessment of functioning can be efficiently ac-
complished with idiographic measures of daily behav-
iors (both problematic and adaptive). Studies of the
incremental validity of such idiographic measures be-
yond global ratings of impairment have not yet been
conducted and are needed.
7. There is currently a paucity of information on
most ADHD assessment measures across gender, race
or ethnicity, age before and after elementary school,
and developmental levels (but see Achenbach &
469
 PELHAM, FABIANO, MASSETTI
Rescorla, 2001, for a good example of comprehensive
normative information). Future research needs to ad-
dress this lack of information.
8. For treatment planning—as well as for studies of
the nature of ADHD (e.g., cognitive deficits)—the
context (i.e., antecedents, consequences, and settings)
of symptoms, and the impact of those symptoms on
functioning, should be collected routinely. The pri-
mary focus of assessment in ADHD should be on an
FBA of impairment. Such an assessment identifies en-
vironmental contexts and socially valid target behav-
iors (not DSM–IV symptoms of ADHD) and facilitates
treatment planning.
9. We have emphasized the need for additional re-
search on the incremental validity of combinations of
assessment approaches (Johnston & Murray, 2003).
Implicit in this recommendation is a focus on the trade-
offs between incremental validity and the cost of as-
sessment—that is, cost effectiveness and cost-benefit
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analysis (Yates & Taub, 2003). For example, do the
day-long, clinic-based evaluations of ADHD that are
common in some settings provide incremental validity
for treatment planning beyond parent or teacher rating
scales, and, if they do, does the incremental benefit
outweigh the additional costs? We strongly suspect the
answer is “no,” but we are not aware of any research on
such questions.
In conclusion, since the advent of the DSM–IV clas-
sification system, significant professional and research
energy has been devoted to constructing ever-more
complex, time-intensive, and costly measures to accu-
rately identify DSM–IV ADHD. This emphasis has re-
duced the use of functional behavioral approaches that
integrate objective assessments and treatments and that
were pioneered and ubiquitously used in the 1960s and
1970s. Because the methods and scales for measuring
ADHD symptoms are so straightforward and take so
little time and cost, it is our hope that clinicians will be-
gin to refocus on the treatment-relevant aspects of as-
sessment that we have outlined herein. We believe that
such an approach will best serve children with ADHD
and their families.
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Received July 31, 2004
Accepted March, 26, 2005

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