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Adult ADHD Self-Report Scale

The Adult ADHD Self-Report Scale (ASRS) is an 18-item self-report questionnaire developed by the World Health Organization (WHO) in collaboration with adult ADHD experts to screen for attention deficit hyperactivity disorder (ADHD) symptoms in adults aged 18 and older, based on DSM-IV diagnostic criteria.^[1] It assesses the frequency of inattention and hyperactivity-impulsivity symptoms over the past six months, with responses rated on a 0-4 Likert scale (never to very often), and includes a validated 6-item screener (Part A) that identifies individuals likely to meet full diagnostic thresholds with 68.7% sensitivity and 99.5% specificity.^[1] The full scale and screener are freely available for clinical and research use, facilitating case identification in general populations and primary care settings without requiring specialized training.^[2] Developed as part of the revision of the WHO Composite International Diagnostic Interview (CIDI), the ASRS was first introduced in 2005 through a study involving 154 adults from the National Comorbidity Survey Replication, where the 6-question screener demonstrated superior performance over the full 18-item version in clinical concordance with blinded psychiatric assessments (κ=0.76 agreement).^[3] The scale's items directly map to the 18 DSM-IV Criterion A symptoms of ADHD, reordered via logistic regression to optimize the screener's predictive accuracy for detecting probable cases.^[1] Although originally aligned with DSM-IV, the ASRS v1.1 remains widely used and valid for DSM-5-TR assessments due to symptom continuity, with scoring thresholds (e.g., 4 or more Part A items in the "sometimes" or higher category) indicating the need for comprehensive diagnostic evaluation.^[4] In response to DSM-5 updates, a revised version—the WHO ASRS for DSM-5 (also called ASRS-5)—was developed in 2017 using machine-learning analysis of pooled data from over 600 adults, incorporating three core DSM-5 symptom items and three executive function probes for enhanced detection.^[5] This 6-item iteration achieves 91.4% sensitivity and 96.0% specificity in general populations at a threshold score of 14 or higher, making it suitable for both community screening and clinical triage, though it emphasizes that positive screens warrant follow-up with structured interviews or clinician-rated tools.^[5] Both versions have been translated into multiple languages and validated across diverse cultural contexts, underscoring their role as accessible, reliable aids in addressing the underdiagnosis of adult ADHD globally.^[6]

Development and History

Origins and Development

The Adult ADHD Self-Report Scale (ASRS) was developed in 2005 through a collaborative effort led by the World Health Organization (WHO), in partnership with researchers from Harvard Medical School and members of the Workgroup on Adult ADHD. This initiative emerged as part of broader revisions to the WHO Composite International Diagnostic Interview (CIDI), aiming to enhance the identification of underrecognized mental health conditions in adults. The primary goal was to create a concise, self-administered screening instrument to detect adult ADHD in general population surveys and clinical outreach programs, including primary care environments, where underdiagnosis remains a significant challenge due to limited awareness and assessment tools. The scale was grounded in the DSM-IV diagnostic criteria for ADHD, with its 18 items carefully adapted to capture the nuanced, often subtler manifestations of inattention, hyperactivity, and impulsivity in adults, as opposed to the more overt symptoms typically observed in children. Key contributors Ronald C. Kessler, from Harvard Medical School, and Lenard A. Adler, from New York University School of Medicine, spearheaded the adaptation process, leveraging epidemiological data and clinical expertise to refine the criteria for adult contexts. Their work involved selecting and validating questions against blind clinical assessments in a targeted sample from the US National Comorbidity Survey Replication. The ASRS was first introduced in a seminal publication in Psychological Medicine in 2005, marking its debut as a standardized tool for ADHD screening.

Versions and Updates

The Adult ADHD Self-Report Scale (ASRS) v1.1 was introduced in 2005 as a refinement of the initial 18-item scale, incorporating items directly derived from DSM-IV criteria for ADHD symptoms in adults. This version streamlined the instrument by identifying six key questions that demonstrated the highest predictive value for ADHD, forming the basis of a brief screener while retaining the full 18-item checklist for more detailed assessment. Developed collaboratively by the World Health Organization (WHO) and the Workgroup on Adult ADHD, the v1.1 emphasized ease of use in general population screening, with the screener achieving sensitivity and specificity rates suitable for initial identification of at-risk individuals. In 2024, researchers affiliated with Harvard Medical School proposed an updated scoring approach for the ASRS v1.1 screener to enhance its clinical utility and diagnostic accuracy. This revision shifted from a binary threshold to a more granular evaluation of symptom frequency, incorporating revised cutoffs that account for varying levels of endorsement on the Likert-style response options (never, rarely, sometimes, often, very often). The changes aimed to better capture symptom severity and reduce false positives in diverse clinical settings, while maintaining compatibility with the original structure.^[7] The ASRS has undergone extensive cultural and linguistic adaptations, with validated translations available in over 26 languages across more than 40 countries by 2024. These include European languages such as German, French, and Spanish, as well as Asian languages like Japanese, Korean, and Chinese, with studies confirming good reliability and partial measurement invariance in non-Western populations. For instance, validations in East Asian cohorts have shown lower average symptom endorsement rates compared to Western samples, highlighting cultural nuances in symptom expression without altering the core items.^[8] To align with DSM-5 criteria, a revised 6-item version—the WHO ASRS for DSM-5 (ASRS-5)—was developed in 2017 using machine-learning analysis of pooled data from over 600 adults, incorporating three core DSM-5 symptom items and three executive function probes for enhanced detection.^[5] Despite these adaptations, the original v1.1 remains the primary version in widespread use, as core ADHD symptom domains show substantial continuity between DSM-IV and DSM-5. By 2025, no comprehensive overhaul of the scale had occurred, though the WHO continues to endorse the ASRS for global mental health screening initiatives due to its accessibility and established role in epidemiological studies.

Structure and Administration

Items and Format

The Adult ADHD Self-Report Scale (ASRS) is an 18-item self-report questionnaire designed to assess the frequency of DSM-IV Criterion A symptoms of attention-deficit/hyperactivity disorder (ADHD) in adults, with nine items addressing inattention and nine items addressing hyperactivity/impulsivity.^[3] Each item inquires about the occurrence of specific symptoms over the past six months, using a 5-point Likert scale where respondents rate frequency as never, rarely, sometimes, often, or very often.^[3] This format allows individuals to reflect on their experiences without requiring clinical interpretation during completion.^[2] A shorter version, known as the ASRS screener or Part A, consists of the first six items, which were selected based on their predictive value for identifying ADHD symptoms and is intended for rapid initial screening.^[3] The full scale and screener are structured for self-administration, available in paper-and-pencil or digital formats, and typically take 5 to 10 minutes to complete without the need for clinician involvement.^[2] For instance, an item from the inattention subscale might read: "How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?" followed by the Likert response options.^[2] This straightforward design facilitates broad use in both clinical and non-clinical settings.^[3] The revised version for DSM-5, known as the ASRS-5, is a 6-item self-report screener that assesses ADHD symptoms over the past six months using a 5-point Likert scale (never to very often).^[5] It includes three items mapping to core DSM-5 symptoms (e.g., difficulty sustaining attention, fidgeting, interrupting others) and three items probing associated executive functions (e.g., procrastination, disorganization, avoidance of tasks requiring effort).^[5] Like the original, it is designed for self-administration in community, primary care, or workplace settings, taking approximately 2-5 minutes to complete.^[5]

Scoring Methods

The Adult ADHD Self-Report Scale (ASRS) employs distinct scoring procedures for its 6-item screener and full 18-item version, focusing on symptom frequency to gauge ADHD likelihood in adults.^[7] For the 6-item screener (Part A), responses are evaluated using a visual threshold plot where each item's frequency options—never, rarely, sometimes, often, very often—are aligned against shaded zones indicating elevated ADHD probability. Traditionally, a response of "sometimes" or higher in four or more items places them in the "high probability" zone, signaling symptoms consistent with ADHD and warranting further assessment.^[9] In the 2024 update from Harvard Medical School, scoring shifts to a full 5-point Likert scale (0 for never, 1 for rarely, 2 for sometimes, 3 for often, 4 for very often), yielding a total score range of 0–24; a cutoff of ≥14 indicates a positive screen, with stratified levels (0–9: low negative; 10–13: high negative; 14–17: low positive; 18–24: high positive) to better differentiate severity and reduce false positives while improving sensitivity for adult populations.^[7] The full 18-item scale (Parts A and B) assesses overall symptom burden without a single total score formula; instead, each item receives a binary endorsement (1 if rated "sometimes" or higher, 0 otherwise), resulting in symptom counts for the inattention subscale (9 items) and hyperactivity/impulsivity subscale (9 items). These domain totals reflect the number of endorsed symptoms, providing separate profiles for inattentive and hyperactive-impulsive presentations.^[9] For the ASRS-5, scoring involves assigning integer weights to responses (0 for never up to 4 for very often, adjusted per item), yielding an additive total score ranging from 0 to 24; a threshold of ≥14 identifies individuals likely warranting further evaluation, with reported sensitivity of 91.4% and specificity of 96.0% in general populations.^[5] Interpretation of all ASRS scores emphasizes screening rather than diagnosis; positive thresholds suggest elevated ADHD risk but necessitate clinical follow-up, including structured interviews and collateral information, to confirm impairment and rule out comorbidities.^[9]

Psychometric Properties

Reliability

The Adult ADHD Self-Report Scale (ASRS) demonstrates good internal consistency, with Cronbach's alpha coefficients typically ranging from 0.80 to 0.90 for the full 18-item scale across various adult samples, reflecting strong coherence among items assessing inattention and hyperactivity-impulsivity symptoms. For the inattention and hyperactivity-impulsivity subscales, alphas generally fall between 0.70 and 0.85, supporting reliable measurement within these domains.^[10] In a validation study, the six-item screener showed alphas of 0.63 to 0.72, slightly lower but still acceptable for a brief tool.^[11] Test-retest reliability of the ASRS is moderate to high, with stability coefficients such as intraclass correlation coefficients (ICCs) or Pearson correlations ranging from 0.60 to 0.80 over intervals of 1 to 3 months in both community and clinical adult populations. For instance, a two-week retest in a Korean sample yielded a reliability estimate of 0.878, indicating robust temporal stability. Kappa coefficients for categorical classifications on the screener have similarly shown moderate agreement (around 0.60 to 0.70) in primary care settings without ADHD. The v1.1 screener version exhibits slightly higher reliability in short-term assessments, with an alpha of approximately 0.75, compared to the full scale in some contexts, making it suitable for efficient screening. Reliability tends to be higher in structured administration (e.g., clinician-guided) versus pure self-report formats, though differences are minimal, and the scale shows few floor or ceiling effects in general adult populations, allowing broad symptom capture. These properties hold across diverse demographics, as evidenced by partial measurement invariance and consistent reliability in a 42-country study spanning languages, cultures, and genders.^[8] Seminal validation by Kessler et al. in 2005 and subsequent cross-cultural analyses confirm the ASRS's stability in varied groups.

Validity

The Adult ADHD Self-Report Scale (ASRS) demonstrates strong construct validity through confirmatory factor analyses that support a two-factor structure consisting of inattention and hyperactivity/impulsivity subscales, consistent with DSM criteria for ADHD symptoms. This bifactor model has been replicated across multiple samples, confirming the scale's alignment with the underlying theoretical constructs of adult ADHD. Criterion validity is evidenced by the 6-item ASRS screener's performance against clinical diagnoses, achieving a sensitivity of 68.7% and specificity of 99.5% in a large population survey, making it effective for identifying probable ADHD cases in primary care settings. These metrics highlight the scale's ability to accurately predict clinical outcomes relative to structured diagnostic interviews. Convergent validity is supported by moderate to high correlations between ASRS scores and established ADHD measures, such as the Conners' Adult ADHD Rating Scale (CAARS), with coefficients ranging from 0.77 to 0.78 for total and inattentive symptoms. Discriminant validity is indicated by low to moderate associations with non-ADHD psychopathology scales, including a correlation of 0.37 with the Beck Depression Inventory, demonstrating the ASRS's ability to differentiate ADHD symptoms from depressive symptoms. Cross-cultural validity of the ASRS has been established in diverse populations across Europe, Asia, and Latin America through multinational studies involving over 72,000 participants from 42 countries, showing good reliability, partial measurement invariance, and consistent factor structure, with adjusted normative cutoffs developed for specific regional groups as of recent analyses.^[8]

Clinical and Research Applications

Screening and Diagnosis

The Adult ADHD Self-Report Scale (ASRS) is primarily utilized as a screening tool in primary care, psychiatry, and occupational health settings to flag potential cases of adult ADHD for further clinical evaluation. Developed by the World Health Organization (WHO) in collaboration with experts, the ASRS enables quick identification of symptomatic individuals among adults aged 18 and older, facilitating early intervention in diverse healthcare environments.^[3]^[12] Its brief format, consisting of an 18-item self-report questionnaire, allows for efficient administration during routine visits, making it suitable for busy clinical practices.^[4] In diagnostic workflows, a positive ASRS screen—typically indicated by elevated scores on the six-item screener—prompts referral for more in-depth assessments, such as structured diagnostic interviews like the Diagnostic Interview for ADHD in Adults (DIVA-5) or comprehensive clinician evaluations incorporating DSM-5 criteria and collateral reports. This stepwise approach ensures that screening results inform but do not replace full diagnostic processes, reducing the risk of misdiagnosis.^[13]^[14] The ASRS offers key benefits in clinical practice, including improved detection rates of ADHD in underserved populations by embedding screening into accessible primary care services, where many adults first seek help for related issues like anxiety or productivity challenges. Its cost-effectiveness and brevity support large-scale screening efforts, potentially increasing identification in resource-limited settings without requiring specialized training.^[15]^[12] Endorsed by the WHO for initial assessments and aligned with American Psychological Association (APA) resources for symptom evaluation, the ASRS is explicitly positioned as a supportive tool rather than a standalone diagnostic instrument, emphasizing the need for professional judgment.^[3]^[16] Real-world applications include its use in U.S. primary care protocols.^[17]^[18]

Use in Research

The Adult ADHD Self-Report Scale (ASRS) has been extensively utilized in epidemiological surveys to gauge the global prevalence of adult ADHD. Notably, it serves as a screening component within the World Health Organization's World Mental Health Composite International Diagnostic Interview (WMH-CIDI), enabling consistent assessment across diverse populations. Data from these surveys, conducted in over 20 countries, indicate a prevalence of persistent adult ADHD averaging 2.8% (range: 0.6–7.3%) based on DSM-IV criteria.^[19] These findings highlight variations by region and demographics, such as higher rates in high-income countries, and underscore the scale's role in informing public health policies on underrecognized adult ADHD.^[20] In longitudinal research, the ASRS supports investigations into the persistence of ADHD symptoms from adolescence into adulthood by providing a standardized measure for repeated assessments. For example, in cohort studies following individuals over several years, the scale has been applied to track symptom trajectories, revealing persistence rates around 50% in those with childhood diagnoses.^[21] Such applications, including five-year outcome evaluations in clinical samples, demonstrate its utility in quantifying symptom stability and identifying factors like comorbidities that influence long-term course.^[22] The ASRS is also instrumental in treatment outcome research, particularly for evaluating pre- and post-intervention changes in ADHD symptoms. In pharmacotherapy trials involving stimulants, it has measured symptom reductions, often showing moderate-to-large effect sizes with improvements in inattention and hyperactivity domains.^[23] Similarly, in cognitive behavioral therapy (CBT) studies, including internet-delivered formats, the scale captures clinically meaningful declines in symptom severity, such as a 30% or greater reduction post-treatment, aiding in the assessment of intervention efficacy.^[24] For subgroup analyses, the ASRS facilitates exploration of ADHD within comorbid conditions, such as substance use disorders, where it identifies elevated symptom endorsement rates among affected individuals.^[15] This has informed studies on overlapping neurodevelopmental spectra, including autism, by highlighting shared inattentive features while differentiating hyperactivity profiles. By 2025, the ASRS's integration into digital health research has grown, supporting app-based tracking and remote monitoring in large-scale studies to evaluate real-time symptom fluctuations and treatment adherence.^[25]

Limitations and Considerations

Potential Biases

The Adult ADHD Self-Report Scale (ASRS), as a self-report instrument, is susceptible to biases inherent to subjective reporting, including recall inaccuracies where respondents may misremember the frequency or severity of symptoms due to memory limitations in retrospective assessments.^[21] Additionally, social desirability bias can lead individuals to underreport symptoms to align with perceived social norms, while lack of insight—common in ADHD—often results in underestimation of impairments, as adults with the disorder tend to rate their inattentive and hyperactive-impulsive symptoms lower than clinical evaluations suggest.^[26]^[27] Cultural biases arise from the ASRS's origins in DSM-IV criteria, which emphasize Western conceptualizations of ADHD, potentially underrepresenting symptoms in non-Western contexts and yielding lower sensitivity in diverse populations.^[28] Cross-cultural studies across 42 countries reveal partial measurement invariance, with significantly higher symptom endorsement in English-speaking Western nations like the US and Canada compared to East Asian and non-English-speaking European countries, indicating cultural influences on symptom reporting that may inflate or deflate scores based on regional norms.^[28] Age and gender effects further introduce bias, as younger adults exhibit lower endorsement thresholds, leading to overendorsement of symptoms, whereas older individuals tend to underreport due to adaptation or diminished recall of lifelong patterns.^[29] Similarly, women often underreport symptoms compared to men, who show higher endorsement rates, potentially stemming from internalized presentations of ADHD in females that align less overtly with scale items.^[29]^[30] Comorbidity with conditions like anxiety and mood disorders creates overlap in symptoms such as inattention and restlessness, which can inflate false positives on the ASRS without targeted differential assessment, as cognitive symptoms in major depressive disorder, for instance, mimic ADHD traits and complicate screening accuracy.^[31]^[32] Administration format introduces minor biases, with web-based versions of ADHD self-report scales, including those akin to the ASRS, yielding higher symptom scores—up to 30-40% above clinical cutoffs—compared to paper formats, possibly due to increased self-disclosure in digital settings influenced by anonymity or demographic differences like younger age in online samples.^[33]

Recommendations for Use

The Adult ADHD Self-Report Scale (ASRS) should always be paired with a comprehensive clinical interview and collateral reports from significant others, such as spouses or employers, to ensure a thorough assessment and mitigate the limitations of self-reported data.^[12]^[4] This multi-method approach helps confirm symptom persistence and distinguishes ADHD from other conditions.^[12] Administrators of the ASRS are recommended to receive training on its purpose and administration to facilitate effective use; this includes clearly explaining the scale's role in identifying attention and organizational challenges, which can reduce respondent anxiety and promote honest self-reporting.^[34]^[35] Such preparation ensures the tool stimulates productive dialogue during follow-up discussions.^[2] For diverse populations, clinicians should utilize population-specific norms and culturally adapted versions of the ASRS to account for variations in symptom expression across languages, countries, and genders, as the scale has demonstrated partial invariance in cross-cultural studies.^[28] Additionally, interpretation must consider comorbidities, such as anxiety or mood disorders, which can overlap with ADHD symptoms and influence scores.^[12]^[36] The ASRS is suitable for periodic screening in at-risk adult populations, such as those with learning difficulties, with administration recommended annually or every six months depending on clinical context to monitor symptom changes over time.^[37] As of 2025, practitioners should incorporate the 2024 scoring revisions, which shifted from a dichotomous system to a full five-point Likert scale (0-4) for greater nuance in assessing symptom severity and improving diagnostic accuracy.^[4] Furthermore, integrating the ASRS with telehealth platforms enables pre-visit self-administration and automated scoring, enhancing accessibility for remote assessments.^[38] To address potential biases briefly, these practices—such as using adapted norms—help minimize cultural or interpretive distortions identified in prior analyses.^[28]

References

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The World Health Organization adult ADHD self-report scale (ASRS)
Jan 21, 2005 · The ASRS includes 18 questions about frequency of recent DSM-IV Criterion A symptoms of adult ADHD. The ASRS screener consists of six out of these 18 questions.
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The questions on the back page are designed to stimulate dialogue between you and your patients and to help confirm if they may be suffering from the symptoms ...
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Insufficient relevant content.
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The Adult Self Report Scale (ASRS) for ADHD screens and diagnoses adult ADHD via questionnaire completed by patient.<|control11|><|separator|>
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