B-BAARS

Brief Barkley Adult ADHD

Rating Scale

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 Contents

Page Numbers

Introduction 2

Development 3

Validation 4

Administration and scoring 4

References 5

Appendix 6

1
 Introduction

Attention deficit hyperactivity disorder (ADHD) is a mental health disorder characterised by

clinically significant symptoms of inattention, hyperactivity and impulsivity, which usually
become evident in childhood (APA, 2013). Around 65% of those diagnosed with ADHD in
childhood have symptoms that persist into adulthood (Faraone et al., 2006), leading to ADHD
in adults being highly overrepresented worldwide (2.8-5.3%) (Polanczyk et al., 2007; Simon et
al., 2009). Adults with ADHD often display adverse outcomes in a wide range of areas such as
problems relating to executive functioning, educational/occupational performance, and
interpersonal relationships. This can be further complicated by comorbidity with other clinical
conditions such as conduct disorder, anxiety, depression and substance use.

There is considerable evidence demonstrating the overrepresentation of individuals with ADHD

in correctional services, with meta-analytical prevalence estimating a 26% classification of
ADHD amongst adult offenders and 30% amongst youth offenders (Young et al., 2015). Studies
of offenders with ADHD have demonstrated disadvantages such as a higher risk of psychiatric
comorbidity and poorer psychosocial adjustment to the prison environment than those without
ADHD (Gudjonsson et al., 2009; Young et al., 2011; Young et al., 2015; Young et al., 2018;
Gonzalez et al., 2015).

Despite this high prevalence among offenders, ADHD is infrequently diagnosed by mental
health teams in prisons (Young et al., 2011; 2018). This may be due to inadequate routine prison
screening protocols, leading to the condition being missed or misdiagnosed. As interventions
are effective in this population it is essential for individuals with ADHD to be identified so they
can be provided with appropriate treatment. Diagnosing ADHD is hampered however by the
need to determine whether symptoms were present in childhood, often relying on self-
reported retrospective recall. The process is further complicated by the diagnostic criteria that
include a wide range of symptoms, many of which overlap with other mental health disorders
(e.g. attentional symptoms are also present in anxiety, depression and substance use
disorders), and high rates of comorbidity.

Screening tools provide a cost-effective way to identify those individuals who might warrant a
comprehensive clinical diagnostic interview. However many simply mirror the 18 core
symptoms and are impractical to deliver in some settings due to time constraints. Furthermore
screens may differ in their predictive validity among different patient samples; for example,
the briefest screening tool available is the 6-item Adult Self-Report Scale (ASRS; Kessler et al.,
2005; 2007) but this solely provides information on the person’s current presentation. Alternative
cut-off scores have been proposed using the ASRS for different populations (van de Glind et
al., 2013).

In order to address the need for a reliable and valid screen that can be easily administered
and that both maximises sensitivity and specificity in predicting a diagnosis of ADHD in an
offender population, we therefore developed the B-BAARS self-rating scale from empirical
data (Young, Gonzalez, Mutch, Mallet-Lambert, O’Rourke, Hickey, Asherson & Gudjonsson,
2016).

2
 Development

The BAARS-IV (Barkley, 2011) is a self-rating scale that was initially developed to assess DSM-IV
symptoms and impairments associated with ADHD in childhood and adulthood. The BAARS-IV
assesses the 18 current and 18 childhood symptoms of ADHD along with age of onset and
several domains of impairment.

Young et al. (2016) aimed to explore the discriminative ability of the BAARS-IV against a
validated clinical diagnostic interview, the Diagnostic Interview for ADHD in Adults (DIVA-2;
Kooji, 2012; Ramos-Quiroga et al., 2016; Pettersson, Soderstrom & Nilsson, 2015). The study
involved 392 male prisoners at HMP Inverness. The sample was almost entirely of White British
ethnicity (99%) with an average age of 30.3 years. The participants completed a
comprehensive battery of measures including the two measures, the BAARS-IV and the DIVA-
2 diagnostic interview. Scores from the BAARS-IV and DIVA-2 assessments were dichotomized
into ‘ADHD’ or ‘no ADHD’, and then sensitivity, specificity, positive predictive value and
negative predictive value were calculated. The ‘area under the curve’ (AUC) was used as the
statistical measure to compare the final diagnostic models of the screening instruments. From
this, the researchers found that the BAARS-IV original scale’s predictive accuracy was not
adequate due to the high number of false positives.

Following this, the researchers aimed to maximise the psychometric properties of the BAARS-
IV by applying statistical procedures that drew on empirical data derived from one half of the
sample. This generated a six item rating scale that best predicted ADHD. These six items
consisted of three drawn from childhood and three from current presentation, with sensitivity
of 0.82, specificity of 0.84, accuracy of 0.84 and an overall AUC of 0.89. The specific items, beta
coefficients and 95% confidence intervals are all included below in Table 1.

Table 1 - Logistic regression model results for child and current BAARS-IV items directly associated with DIVA-2
interview-derived ADHD diagnosis (n = 195).

BAARS items B OR

Childhood
Left seat in classroom and other situations in which being seated was expected 1.16 3.18

Lost things necessary for tasks and activities 0.98 2.66

Interrupted or intruded on others 1.52 4.58

Current
Fidgets with hands or feet or squirm in seat 1.01 2.74

Have difficulty engaging in leisure activities or doing fun things quietly 1.35 3.85

Have difficulty waiting turn 1.32 3.78

Items previously selected from stepwise model, forward selection from the pool of all BAARS items

3
 Validation

For validation, the selected items and the weighted probability scores were tested in a
separate half of the sample. The internal validation produced an AUC value of 0.81.

These findings confirm potential usefulness of the B-BAARS to screen for ADHD in different
samples of prison inmates.

Administration and Scoring

A copy of the B-BAARS can be found in the Appendix. It is a self-rating scale that should be
administered individually. Instructions are provided at the top of each scale as follows:

“Please read each statement and mark an ‘X’ next to the response that best describes your
behaviour during the given timeframe.”

The respondent is required to mark their response for each question in one of four boxes,
‘Never/Rarely’, ‘Sometimes’, ‘Often’ and ‘Very Often’. The first three questions are related to
when the respondent was a child aged 5-12, and the last three questions refer to the past six
months.

Scoring

If there are three or more responses marked ‘X’ in the category of either “Often” or “Very
Often” across both the child and adult domains, this indicates the likelihood that the
respondent has clinically significant symptoms of ADHD, and a comprehensive clinical
assessment of ADHD is recommended (e.g. using the ACE or ACE+ (http://www.psychology-
services.uk.com/resources.htm).

4
 References
American Psychological Association (2013). Diagnostic and statistical manual of mental disorders. American
Psychiatric Association: Washington, DC.

Barkley, R. A. (2011). Barkley Adult ADHD Rating Scale-IV (BAARS-IV). Guildford: New York, NY.

Faraone, S. V., Biederman, J., & Mick, E. (2006). The age-dependent decline of attention deficit hyperactivity
disorder: a meta-analysis of follow-up studies. Psychological Medicine, 36, 159-165.

Gonzalez, R. A., Velez-Pastrana, M. C., Ruiz Varcarcel, J. J., Levin, F. R., & Albizu-Garcia, C. E. (2015). Childhood
ADHD symptoms are associated with lifetime and current illicit substance-use disorders and in-site health risk
behaviors in a representative sample of latino prison inmates. Journal of Attention Disorders, 19, 301-312.

Gudjonsson, G., Sigurdsson, J. F., Young, S., Newton, A. K., & Peersen, M. (2009). Attention deficit hyperactivity
disorder (ADHD). How do ADHD symptoms relate to personality among prisoners? Personality and Individual
Differences, 47, 64-68.

Kessler, R. C., Adler, L. A., Gruber, M. J., Sarawate, C. A., Spencer, T., & Van Brunt, D. L. (2007). Validity of the
World Health Organisation Adult ADHD Self-Report Scale (ASRS) screener in a representative sample of health
plan members. International Journal of Methods in Psychiatric Research, 16, 52-65.

Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E., Howes M. J., Jin, R., Secnik, K., Spencer, T.,
Ustun, T. B., Walters, E. E. (2005). The World Health Organisation Adult ADHD Self-Report Scale (ASRS): a short
screening scale for use in the general population. Psychological Medicine, 35, 245-256.

Pettersson, R., Soderstrom, S. & Nilsson, K. W. (2018). Diagnosing ADHD in adults: an examination of the
discriminative validity of neuropsychological tests and diagnostic assessment instruments. Journal of Attention
Disorders, 22, 1019-1031

Ramos-Quiroga, J. A., Nasillo, V., Richarte, V., Corrales, M., Palma, F., Ibanez, P. . .Kooji, J. J. (2016). Criteria and
concurrent validity of DIVA 2.0: a semi-structured diagnostic interview for adult ADHD. J Atten Disord, Epub.

Van de Glind, G., van den Brink, W., Koeter, M., Carpentier, P. van Emmerik-van Oortmerssen, K., Kaye, S. .
.Levin, F. R. (2013). Validity of the adult ADHD self-report scale (ASRS) as a screener for adult ADHD in treatment
seeking substance use disorder patients. Drug Alcohol Depend, 132(3), 587-596.

Young, S., Adamou, M., Bolea, B., Gudjonsson, G., Muller, U., Pitts, M., Thome, J. & Asherson, P. (2011). The
identification and management of ADHD offenders within the criminal justice system: a consensus statement
from the UK Adult ADHD Network and criminal justice agencies. BMC Psychiatry, 11:32.
http://www.biomedcentral.com/1471-244X/11/32

Young, S., Gonzalez, R. A., Mutch, L., Mallet-Lambert, I., O’Rourke, L., Hickey, N., Asherson, P., Gudjonsson, G. H.
(2016). Diagnostic accuracy of a brief screening tool for attention deficit hyperactivity disorder in UK prison
inmates. Psychological Medicine, 46, 1449-1458.

Young, S., Gudjonsson, G., Chitsabesan, P., Colley, B., Farrag, E., Forrester, A., Hollingdale, J., Kim , K., Lewis. A.,
Maginn, S., Mason, P., Ryan, S., Smith, J., Woodhouse, E., Asherson, P. (2018). Identification and treatment of
offenders with attention-deficit/hyperactivity disorder in the prison population: A practical approach based
upon expert consensus. BMC Psychiatry, 18:281 https://doi.org/10.1186/s12888-018-1858-9

Young, S., Moss, D., Sedgwick, O., Fridman, M., & Hodgkins, P. (2015). A meta-analysis of the prevalence of
attention deficit hyperactivity disorder in incarcerated populations. Psychological Medicine, 45, 247-258.

5
Appendix

6
 B-BAARS
Brief version of the Barkley Adult
ADHD Rating Scale

Please read each statement and mark an ‘X’ next to the response that best describes your
behaviour during the given timeframe.

When I was a child aged 5-12 years, I...

Never/Rarely Sometimes Often Very Often

1. Left my seat in classroom or in

other situations in which remaining
seated was expected

2. Lost things necessary for tasks or

activities

3. Interrupted or intruded on others

During the past 6 months, I…

Never/Rarely Sometimes Often Very Often

4. Fidgeted with my hands or feet

or squirmed in my seat

5. Had difficulty engaging quietly

in leisure activities or fun tasks

6. Had difficulty awaiting my turn

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© Psychology Services Limited, 2018
https://www.psychology-services.uk.com/adhd