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The introduction of rating scales for psychiatric assessment began in the 1960s, and by the 1980s they had become standard practice in ADHD diagnosis following the publication of the DSM-III. Rating scales continue to be used today, albeit in a format that’s evolved and refined since those early introductions.
However, our understanding of ADHD has progressed phenomenally since the 1960s.
We now have access to technology and research that simply weren’t available when the rating scale became a foundational element of ADHD assessments. We also now work in a new era of ADHD understanding, where patients have knowledge of ADHD symptoms, testing methodologies, and treatments before ever setting foot inside a clinic.
In this landscape, are rating scales really enough anymore? Do they still fit the needs and expectations of not just clinicians, but patients too?
The patient of 2025 has a wide choice of healthcare providers – both local to them in-clinic and more remotely via telehealth. Patients expect a quality standard of ADHD care, and the methodology used by clinicians to test and treat ADHD is a major platform on which care is judged.
Rating scales are highly subjective and carry the bias (often subconsciously) of whoever is completing them. Symptoms can be over- or underreported or even missed entirely. Often rating scales aren’t returned, or when they are, they may be only partially complete or returned late and only after much chasing by the clinician.
There can also be huge variations in feedback from parents, patients, and teachers. Last year, data on nearly 8,000 children aged 4-17 was analyzed to assess agreement between parents and teachers on reporting hyperactivity and inattention. Agreement on these two core symptoms of ADHD, between two of the key respondents on rating scales (parents and teachers), was low (a weighted kappa of just 0.34).
If we can’t rely on the data from rating scales or receive this data promptly, should we still be relying on them so heavily in our assessments?
There’s a cost to this unreliability. A reliance on rating scales alone, can contribute to increased pressure on our already overstretched mental health services. When we can’t quickly and accurately diagnose conditions like ADHD, we see waitlists grow, secondary and follow-up consultations increase, and uncertainty creep in.
None of this is lost on patients, who are only too aware thanks to the headlines from social media about the delays in accessing ADHD services. Patients expect more, and as professionals working in ADHD, we must deliver on that.
The introduction of rating scales changed how we tested for ADHD. However, progress is continual, and we now have tools that can add to our assessments, deepen our understanding of symptoms, and add confidence to diagnoses.Digital ADHD tests can provide clinicians with objective data on their patients’ performance and symptoms in a controlled test environment. The data is readily benchmarked against the results of people of the same age and sex at birth without ADHD to offer a clear comparison. Results are available instantly, and tests can take place in-clinic or remotely via telehealth.
The data from objective tests isn’t intended to replace rating scales and other elements of ADHD assessments, such as clinician interviews. Instead, digital ADHD tests are designed to provide clinicians with additional data and insights that can be used to gain a more complete picture of a patient’s symptoms.
Incorporating objective tests into an ADHD assessment can take some of the uncertainty out of diagnosing ADHD. Rather than relying on the subjective and often conflicting reports of rating scales, clinicians are presented with objective data that is easy to interpret and analyze. Removing this uncertainty and adding to the volume of data available on a patient can help reduce the time to diagnosis, aid diagnostic decision-making, reduce appointment length, and increase clinician confidence.
There’s also a role for objective data during ADHD treatment. Rating scales aren’t designed to capture response to treatment over time. This means that patients may actually experience a lessening of symptoms as a result of treatment but still report symptom presence or even symptom worsening in rating scales. By contrast, digital ADHD tests can be repeated after starting treatment and results compared to baseline results at diagnosis to show the impact of medication on ADHD symptoms. These tests can help to streamline the often, time-consuming process of titration and add confidence to the difficult decisions of how to adjust medication dosages.
Using objective data can also help clinicians build trust with patients and communicate more effectively and openly. ADHD is complex, and when assessments rely too heavily on rating scales, patients can struggle to understand how ADHD symptoms affect them. The clinician’s assessment can bring new insights to what they’ve experienced and documented in rating scales and interviews. However, it doesn’t introduce new data. By contrast, a digital ADHD test can capture and visually represent a patient’s symptoms in a way that can be seen in physical reports that clinicians can share and discuss with patients, and in doing so, aids their understanding.
The use of digital ADHD tests can also help to standardize the ADHD pathway across locations of a multisite provider, and across regions and state lines. There is considerable variation in which rating scales clinicians use; objective tests help to introduce consistency. By adopting a consistent approach, a clinic can establish a strong brand and a reputation for reliable, high-quality ADHD care that patients can rely on.
As technology, particularly AI, continues to advance and become mainstream within health services, it’s easy to see patient expectations for data-led care increase. Wearable technology, such as smartwatches and fitness monitors, are already widely used and innovations in mobile-based ADHD testing are beginning to roll out. Technological solutions to ADHD testing and treatment should no longer be considered novel or supplementary. They are increasingly part of the mainstream solution to the challenge of ADHD and have an important role to play in delivering a high-quality standard of care to patients.
The other great strength of technology is its potential to connect and unite us – to bring conversations into the mainstream and to create platforms for advocacy. The ADHD Expert Consortium is an example of this. It brings together people from across state and regional boundaries, united by a commitment to shape the future of ADHD care and pursue quality.
As professionals working in ADHD care, the expectation (and desire) to deliver a quality service for our patients is clear. The work of the Consortium and other advocates demonstrates the will to make the lives of the people we work with better. The more challenging issue is how do we define quality in ADHD care?
Data has a role to play here too. There are three core areas for ADHD care success metrics:
By tracking these metrics, clinics can measure in real-time and in real terms what impact they are having, where changes are working, and where improvement is needed.
However, we cannot pursue these improvements only at the local or clinic level. Clinicians, virtual health service providers, and digital health tech companies must unite to improve and standardize measurement-based care. Partnerships are needed to build on the evidence base, to improve not just the way we diagnose ADHD in regional clusters or pockets, but how we scale those changes across state lines to ensure every patient has access to the highest quality of care. Working together is the best way to scale at pace and ensure both technology and the voice of the clinician are amplified.
Public awareness of ADHD is higher now than ever before. That’s a good thing; it means that those conversations that many of us working in the field have had for years are gathering attention at last. It also means expectations have grown. Patients are not only more aware of the symptoms of ADHD than they were before, but they’re also knowledgeable of the tools and treatments available. Clinicians who capitalize on these opportunities, by using objective tools, by measuring and improving performance, and by embracing new technologies, position themselves to be seen by patients as those who provide quality in ADHD care – who have listened to patient expectations, and delivered.
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